While the fields of health care and public health have many evidence-based innovations, knowledge disseminates slowly, if at all. The failure to implement health interventions that have been demonstrated to be cost-effective by high-quality research affects both high-income and low-income countries.(1)
For example, a small group of obstetricians and nurses in a community hospital were able to safely reduce their cesarean delivery rates from 26% to 15%, but rates remained high for most of the other obstetricians in the hospital.(2) Furthermore, studies have revealed that simple, cheap antibiotics are best for first ear infections in children. Yet in a study of 12000 children with first ear infections in the Colorado Medicaid program, 30% received unnecessary, expensive, and hazardous antibiotics, at an excess cost of over $200,000 per year.(3)
Analogous problems exist in the field of global health. “Low-income countries face additional challenges to disseminating research evidence such as the weakness of their health systems, the lack of professional regulation and a lack of access to evidence.”(4) Best practices and innovations can take years, if not decades, to become standard practices. A pressing question in global health today is how to spread best practices. There is a need to strengthen institutions and mechanisms that can systematically promote interactions between researchers, policy-makers, and health workers who are positioned to influence the uptake of research findings.
The gap between evidence and implementation is due to two main factors: tradition-bound individuals and institutions who insist on practicing their way, and a disconnect between those who create the evidence base and those who are positioned to implement the innovation. The underlying problem is in “the way in which the production of evidence is organized institutionally with highly centralized mechanisms, whereas the application of that science is highly decentralized. This social distance prevails because scientists are more oriented to the international audiences of other scientists for which they publish than to the needs of practitioners, policy makers, or the local public.”(5)
Unite For Sight utilizes four main strategies to spread best practices and encourage innovation. First, Unite For Sight’s Global Health University seeks to educate volunteers, students, and global health organizations through online courses in social entrepreneurship, community eye health, cultural competency, and research methodology among others. Secondly, the Global Impact Corps provides education about best practices through pre-training courses and an immersive global health experience. The Community Fellows Program with chapters in North America also provides education about best practices and an immersive domestic public health experience. Lastly, the Global Health and Innovation Conference convenes more than 2,200 individuals from 55 countries who are leaders in global health and international development, public health, eye care, medicine, social entrepreneurship, nonprofits, philanthropy, microfinance, human rights, anthropology, health policy, advocacy, public service, environmental health, and education. During the conference, participants collaborate on strategies to identify global problems, engage in social entrepreneurship, and network with leading innovators, organizations, universities, and other change-makers.
There is a long history of trying to understand the spread of ideas and actions within social systems. Examples include the dissemination of ideas in nations(6), crowds(7), physicians adopting a new drug or evidence-based medical practice(8), public health officers adopting a new policy,(9) and organizations adopting new administrative practices.(10)
A basic notion of diffusion theory is that a new idea is adopted very slowly during the early stages of its diffusion process.(11) Then, if the innovation is perceived as relatively advantageous by its early adopters, its rate of adoption takes off as the early adopters share their favorable experiences regarding the innovation with potential adopters.(12) Three main factors influence the successful dissemination of an intervention: 1) the perceptions of the innovation, 2) characteristics of individuals who may adopt the change, and 3) contextual factors, especially involving communication, incentives, leadership, and management.(13)
The first factor—the perception of the innovation—involves the attitude of a community, organization, or leader toward an intervention. Innovations spread faster when they are perceived to have these five attributes: benefit, compatibility, simplicity, trialability, and observability.(14) ‘Benefit’ is an important determinant of success because individuals and institutions are more likely to adopt an innovation if they believe it will benefit their endeavors. For this same reason, the innovation must be compatible with the values, beliefs, and current needs of individuals.
The second cluster of factors that explain the rate of spread of an innovation include the personalities of individuals among whom spread might occur, i.e., the potential “adopters.” The most willing people to adopt a change are called “innovators”—people who are distinguished by their entrepreneurial ability, tolerance of risk, usually wealthier, “mavericks.” Early adopters are next, and include people who are well-connected socially and have the resources to try new things. In addition to being closely tied to the characteristics of a population, this factor also includes the institutional environment, namely the presence of organizations that may nurture or discourage innovation. For example, organizations or societies that have resources, give praise, and foster social interactions see a faster dissemination of change.
The third and perhaps most important factor that affects the successful dissemination of a public health innovation is the local reality or contextual environment into which a program or policy will be implemented. This includes the historical and social elements which merge together to shape the form and attitude of the community. Local worlds—the networks of relationships and communities in which we live and experience social life—have substantial influence and must be taken into account when predicting and evaluating the successful spread of an innovation.
Past research shows that the diffusion of innovations is essentially a social process consisting of people talking to others about the new idea as they gradually adopt the innovation.(15) “Recently, the diffusion of innovation framework has evolved and expanded from early models of communication process that tended to be linear and individual, to more interactive models of communication in which participants create and share information to arrive at mutual understandings of new values, new concepts, and new practices. This global framework conceptualizes many kinds of social change, including change through processes of public dialogue and civic participation, change within organizations, as well as change through public agenda setting and media effects. ”(16)
Jim Yong Kim expands on this idea in his discussion of “communities of practice”. Communities of practice are groups of people who share a concern or a passion for something (such as introducing health interventions and projects in developing countries) and they share best practices and innovations as they continue to regularly interact.
“Our experience has been that local practitioners, including doctors, nurses, and community health workers, are a rich source of information about the enablers and impediments to successful program design and implementation. To capture knowledge and disseminate learning, a core agenda is to engage practitioners. We aim to disseminate best practices by creating communities of practice around specific global health delivery challenges that will include professionals at all levels from around the world. We are hopeful that this community will generate and share knowledge that would otherwise be difficult to uncover. We hope to foster more partnerships between academic institutions and organizations, often NGO’s or public sector services organizations that deliver health care in resource poor settings. Such organizations are the source of much of the innovation in global health care delivery, but they often lack the resources to capture or disseminate the knowledge they discover in the process of delivering care. Academic institutions can contribute to the improvement of care delivery through capturing experiences and insights, building analytic frameworks and disseminating knowledge.”(17)
In order to address the knowledge-action gap, a standardized, evidence-based system of evaluation and implementation within the global health community is needed. In other words, implementation research and increased transparency are needed in order to get at this goal of best practices. Like the medical sector, the public health sector should evaluate its own actions. Whereas epidemiological research provides public health with the “what,” “where,” “why,” and “who,” public health initiatives need to start funding implementation research to understand “how” successful programs can be emulated. The urgency and validity of the need for best practices to be spread is strengthened by the fact that health workers and researchers have a joint ethical responsibility to acquire scientific knowledge that matters to public health and to apply this knowledge in practice.
Global public health interventions often have unintended consequences due to lack of knowledge of the three factors that determine the success of an intervention: perceptions, individual characteristics, and environmental context. For these reasons, there needs to be formal mechanisms in the public health sector to find effective innovations and establish social interactions between other health professionals to encourage dissemination.
(1) Haines A, Kuruvilla S, Borchert M. Bridging the implementation gap between knowledge and action for health. Bull World Health Org 2004; 82: 724–33.
(2) Flamm B, Kabcenell A, Berwick DM, Roessner J. Reducing Cesarean Section Rates While Maintaining Maternal and Infant Outcomes. Boston, Mass: Institute for Healthcare Improvement; 1997.
(3) Berman S, Byrns PJ, Bondy J, Smith PJ, Lezotte D. Otitis media-related antibiotic prescribing patterns, outcomes, and expenditures in a pediatric Medicaid population. Pediatrics. 1997;100:585-592.
(4) Haines A, Kuruvilla S, Borchert M. Bridging the implementation gap between knowledge and action for health. Bull World Health Org 2004; 82: 724–33.
(5) Diffusion Theory and Knowledge Dissemination, Utilization, and Integration in Public Health Annual Review of Public Health. 2009;30:151 -74.
(6) Tarde G. Social Laws: An Outline of Sociology. Kitchener, Ontario: Batoche. 1898; 94–95.
(7) Le Bon G. The Crowd: A Study of the Popular Mind. Dunwoody, GA: Norman S. Berg. 1982.
(8) Coleman JS, Menzel H, Katz E. Medical Innovation: A Diffusion Study. New York: Bobbs Merrill. 1957.
(9) Becker MH. Predictors of innovative behavior among local health officers. Public Health Rep. 1969. 84:1063–68.
(10) Wolfe R. Organizational innovation: review, critique, and suggested research directions. J. Manag. Stud. 1994. 31:405–31.
(11) Rogers EM. Diffusion of Innovations. 4th ed. New York, NY: Free Press; 1995.
(12) Diffusion of innovations theory and work-site AIDS programs. Journal of health communication. 1998; 3 (1):17 -28.
(13) Berwick DM. Disseminating Innovations in Health Care. Journal of the American Medical Association. 2003; 289 (15):1969-1975.
(15) Rogers EM. Diffusion of Innovations. 4th ed. New York, NY: Free Press; 1995.
(16) Moseley, S.F. Everett Rogers’ diffusion of innovations theory: Its utility and value in public health. Journal of Health Communication. 2004; 9(1): 149-151.
(17) Kim, Rhatigan, Jain, Porter “Values to Value” article in forthcoming lancet on Values in Global Health.