December 10, 1997

The Diffusion of Innovations Model and Outreach from the National Network of Libraries of Medicine to Native American Communities

by

Everett M. Rogers and Karyn L. Scott

Department of Communication and Journalism
University of New Mexico
Albuquerque, New Mexico87131-1171

(505) 277-7569
FAX: (505) 277-4206

,

Draft paper prepared for the National Network of Libraries of Medicine, Pacific Northwest Region, Seattle.

The Diffusion of Innovations Model and Outreach from the National Network of Libraries of Medicine to Native American Communities

Everett M. Rogers and Karyn L. Scott*

"...I still consider good information to be the best medicine."
(Dr. Michael E. DeBakey, Chair, Board of Regents, National Library of Medicine)

Introduction

The purpose of the present essay is to derive lessons learned from past research on the diffusion of innovations that could be utilized in medical library outreach. We place a main emphasis on how to evaluate the effects (impacts) of such medical library outreach activities on the intended audience of health care professionals, particularly Native Americans in the Pacific Northwest of the United States. We stress the promising potential of new communication technologies like the Internet in delivering medical library information resources; examples are the Internet GRATEFUL MED and the WWW-based free access to MEDLINE.

Outreach Projects

The goal of outreach activities is to affect the knowledge, attitudes, and/or practices of the target audience. Knowing which level or levels of change one wants to effect (knowledge, attitudes, and/or practices) is necessary for successful planning, implementation, and evaluation of outreach activities for the target audience. The main target audience for the outreach activities discussed here are health practitioners like medical doctors, dentists, nurses, pharmacists, physician assistants, medical librarians, therapists, and health aides. Special attention is given to health care professionals in rural and remote areas, where information needs are likely to be greatest.

Starting in 1987, a series of Congressional initiatives urged the National Library of Medicine (NLM) to focus on outreach activities to convey scientific findings to health professionals and thus, indirectly, to the public. Ideally, these library outreach activities should be directed to filling the information needs of the intended audience of health care professionals. These information needs are not uniform across various regions, communities, and ethnic populations in the United States. Accordingly, the exact nature of outreach activities varies widely as they are carried out (1) by the eight regional medical libraries (of which the University of Washington Medical Library is one), (2) by the 4,500 member units of the National Network of Libraries of Medicine, and (3) by other units (Figure 1).

Figure 1. Main components of the Flow of Medical Information

During the first half of the 1990s, the National Library of Medicine supported 300 outreach projects in the United States (Wallingford and others, 1996). One of NLM's most important initiatives has been the Internet GRATEFUL MED, the first product of the User Access Services project of NLM's System Reinvention Initiative. The goal of Internet GRATEFUL MED is to provide users with assisted interactive retrieval from multiple information resources as NLM's major systems and databases evolve.

Between 1990 and 1992, contracts for GRATEFUL MED demonstration and training projects in the amount of $25,000 or less were awarded to libraries in academic centers, hospitals, other health care institutions, and in health professional organizations. The goals of these projects was to reach out to rural, underserved, minority, and unaffiliated health professionals to demonstrate or teach them to use GRATEFUL MED as an easy and convenient way to obtain up-to-date medical information for use in their practices. The GRATEFUL MED demonstration and training projects typically lasted 18 months, and usually entailed brief, hands-on demonstrations.

These projects, however, had no built-in evaluation system or long-term follow-up to encourage the continued use of GRATEFUL MED. Additionally, the practice context of the health professionals who were to use GRATEFUL MED was not studied in these projects. The outreach projects could use any particular strategy to reach their intended audiences, and a variety of such strategies were utilized. The most common were one-on-one training of health professionals and training sessions of 10 to 12 health professionals (on site) in using the Internet GRATEFUL MED.

This outreach program has encouraged the National Library of Medicine to invite a set of consultants from various fields to author a series of white papers about lessons learned from evaluation research on outreach activities in related fields. The present report is one of these white papers, summarizing how the diffusion of innovations model suggests outreach strategies that could be applied to the outreach activities by medical libraries in the United States.

Accomplishments of the Outreach Projects

What have the outreach activities of the early 1990s achieved? Over 20,000 health professionals have learned about accessing the NLM's information resources (Wallingford and others, 1996). Overall use of these information resources has increased considerably, perhaps in part due to the NLM-supported outreach activities.

  1. The number of searches of the NLM data-bases increased from 4 million in 1989 to 7 million in 1994.
  2. Users of GRATEFUL MED constituted less than one-third of all NLM searches in 1989, and increased to more than two-thirds by 1994. This trend suggests the powerful changes underway that are due to the increasing use of the Internet and to other new communication technologies.

Despite these growing rates of use of NLM information resources, the National Library of Medicine feels that much remains to be done to effectively reach the total population of U.S. health care professionals. Obviously, the 20,000 individuals contacted by the 300 outreach projects are a tiny portion of all health care professionals in the United States. A further related problem is that the present users of NLM information resources are undoubtedly characterized by higher socioeconomic status, more formal education and more specialized training, and by location in more urban areas. Active information-seeking by professionals in any field usually is characteristic of individuals (and organizations) who are elite, research-oriented, and endowed with adequate resources. The health care professionals who most need medical information resources are at present least likely to receive them. This problem is an example of the general tendency for widening information gaps1 (Rogers, 1995, pp. 429-440). In order to help close these gaps, the NLM, since mid-1997, has provided all Americans with free access to MEDLINE through the World Wide Web (WWW). Previously, users of MEDLINE had to pay for their searches. Many other strategies could be utilized to narrow the information gaps presently existing, such as targeting outreach activities to specific audience segments like those in rural and isolated areas, inner cities, etc.

The information gap problem is particularly important for Native Americans in the Pacific Northwest states of Alaska, Idaho, Montana, Oregon, and Washington, where 267,127 Native American people reside (14.5 percent of the total population of Native American people in the U.S.). Compared to the non-Native American population of the United States, Native Americans are a particularly disadvantaged minority population, characterized by rural and remote residence, widespread poverty and unemployment, and serious health problems, such as alcohol abuse, accidents, cirrhosis, homicide, suicide, pneumonia, diabetes, and heart disease. Health professionals who serve Native American patients are likely to be culturally heterophilous2 with them, so that such interaction faces difficult intercultural communication problems.

Key Variables in the Diffusion Model

The current section presents the model of diffusion and describes the model's key variables. First, however, a brief history of diffusion research is presented. The paradigm for diffusion research can be traced to the rural sociology research tradition, which began in the 1940s. Rural sociology is a subfield of sociology that focuses on the social problems of rural life. One rural sociology study in particular influenced the methodology, theoretical framework, and interpretations of later students in the rural sociology tradition, and in other diffusion research traditions. Ryan and Gross (1943) investigated the diffusion of hybrid seed corn among Iowa farmers. Hybrid seed was made available to Iowa farmers in 1928. The hybrid vigor of the new seed increased corn yields on Iowa farms, hybrid corn varieties withstood drought better than the open-pollinated seed they replaced, and hybrid corn was better suited to harvesting by mechanical corn pickers. By 1941, about thirteen years after its first release, the innovation was adopted by almost 100 percent of Iowa farmers. Ryan and Gross studied the rapid diffusion of hybrid corn in order to obtain lessons learned that might be applied to the diffusion of other farm innovations. However, the intellectual influence of the hybrid corn study reached far beyond the study of agricultural innovations, and outside of the rural sociology tradition of diffusion research. Since the 1960s, the diffusion model has been applied in a wide variety of disciplines such as education, public health, communication, marketing, geography, general sociology, and economics. Diffusion studies in these various disciplines have ranged from the rapid diffusion of the Internet to the nondiffusion of the Dvorak keyboard (in typewriters and computers).

Diffusion is the process by which (1) an innovation (2) is communicated through certain channels (3) over time (4) among the members of a social system. Diffusion is a special type of communication concerned with the spread of messages that are perceived as new ideas. The four main elements in the diffusion of new ideas are (1) the innovation, (2) communication channels, (3) time, and (4) the social system (Figure 2).

Figure 2. Diffusion is the process by which (1) an Innovation is (2) Communicated through certain Channels (3) over Time (4) among the members of a Social System

The Innovation

An innovation is an idea, practice, or object that is perceived as new by an individual or other unit of adoption. The characteristics of an innovation, as perceived by the members of a social system, determine its rate of adoption. Figure 2 shows the relatively slower, and faster, rates of adoption for three different innovations. Why do certain innovations spread more quickly than others? The characteristics which determine an innovation's rate of adoption are:

(1) relative advantage, (2) compatibility, (3) complexity, (4) trialability, and (5) observability.

  • Relative advantage is the degree to which an innovation is perceived as better than the idea it supersedes. The degree of relative advantage may be measured in economic terms, but social prestige, convenience, and satisfaction are also important factors. It does not matter so much if an innovation has a great deal of objective advantage. What does matter is whether an individual perceives the innovation as advantageous. The greater the perceived relative advantage of an innovation, the more rapid its rate of adoption will be.
  • Compatibility is the degree to which an innovation is perceived as being consistent with the existing values, past experiences, and needs of potential adopters. An idea that is incompatible with the values and norms of a social system will not be adopted as rapidly as an innovation that is compatible. The adoption of an incompatible innovation often requires the prior adoption of a new value system, which is a relatively slow process.
  • Complexity is the degree to which an innovation is perceived as difficult to understand and use. Some innovations are readily understood by most members of a social system; others are more complicated and will be adopted more slowly. New ideas that are simpler to understand are adopted more rapidly than innovations that require the adopter to develop new skills and understandings.
  • Trialability is the degree to which an innovation may be experimented with on a limited basis. New ideas that can be tried on the installment plan will generally be adopted more quickly than innovations that are not divisible. An innovation that is trialable represents less uncertainty to the individual who is considering it for adoption, who can learn by doing.
  • Observability is the degree to which the results of an innovation are visible to others. The easier it is for individuals to see the results of an innovation, the more likely they are to adopt it. Such visibility stimulates peer discussion of a new idea, as friends and neighbors of an adopter often request innovation-evaluation information about it.

In summary, then, innovations that are perceived by individuals as having greater relative advantage, compatibility, trialability, observability, and less complexity will be adopted more rapidly than other innovations.

Communication Channels

The second main element in the diffusion of new ideas is the communication channel. Communication is the process by which participants create and share information with one another in order to reach a mutual understanding. A communication channel is the means by which messages get from one individual to another. Mass media channels are more effective in creating knowledge of innovations, whereas interpersonal channels are more effective in forming and changing attitudes toward a new idea, and thus in influencing the decision to adopt or reject a new idea. Most individuals evaluate an innovation, not on the basis of scientific research by experts, but through the subjective evaluations of near-peers who have adopted the innovation.

Time

The third main element in the diffusion of new ideas is time. The time dimension is involved in diffusion in three ways. First, time is involved in the innovation-decision process. The innovation-decision process is the mental process through which an individual (or other decision-making unit) passes from first knowledge of an innovation to forming an attitude toward the innovation, to a decision to adopt or reject, to implementation of the new idea, and to confirmation of this decision. An individual seeks information at various stages in the innovation-decision process in order to decrease uncertainty about an innovation's expected consequences. The second way in which time is involved in diffusion is in the innovativeness of an individual or other unit of adoption. Innovativeness is the degree to which an individual or other unit of adoption is relatively earlier in adopting new ideas than other members of a social system. There are five adopter categories, or classifications of the members of a social system on the basis on their innovativeness: (1) innovators, (2) early adopters, (3) early majority, (4) late majority, and (5) laggards.

  • Innovators are the first 2.5 percent of the individuals in a system to adopt an innovation. Venturesomeness is almost an obsession with innovators. This interest in new ideas leads them out of a local circle of peer networks and into more cosmopolite social relationships. Communication patterns and friendships among a clique of innovators are common, even though the geographical distance between the innovators may be considerable. Being an innovator has several prerequisites. Control of substantial financial resources is helpful to absorb the possible loss from an unprofitable innovation. The ability to understand and apply complex technical knowledge is also needed. The innovator must be able to cope with a high degree of uncertainty about an innovation at the time of adoption. While an innovator may not be respected by the other members of a social system, the innovator plays an important role in the diffusion process: That of launching the new idea in the system by importing the innovation from outside of the system's boundaries. Thus, the innovator plays a gatekeeping role in the flow of new ideas into a system.
  • Early adopters are the next 13.5 percent of the individuals in a system to adopt an innovation. Early adopters are a more integrated part of the local system than are innovators. Whereas innovators are cosmopolites, early adopters are localites. This adopter category, more than any other, has the greatest degree of opinion leadership in most systems. Potential adopters look to early adopters for advice and information about the innovation. This adopter category is generally sought by change agents as a local missionary for speeding the diffusion process. Because early adopters are not too far ahead of the average individual in innovativeness, they serve as a role-model for many other members of a social system. The early adopter is respected by his or her peers, and is the embodiment of successful, discrete use of new ideas. The early adopter knows that to continue to earn this esteem of colleagues and to maintain a central position in the communication networks of the system, he or she must make judicious innovation-decisions. The early adopter decreases uncertainty about a new idea by adopting it, and then conveying a subjective evaluation of the innovation to near-peers through interpersonal networks.
  • Early majority is the next 34 percent of the individuals in a system to adopt an innovation. The early majority adopt new ideas just before the average member of a system. The early majority interact frequently with their peers, but seldom hold positions of opinion leadership in a system. The early majority's unique position between the very early and the relatively late to adopt makes them an important link in the diffusion process. They provide interconnectedness in the system's interpersonal networks. The early majority are one of the two most numerous adopter categories, making up one-third of the members of a system. The early majority may deliberate for some time before completely adopting a new idea. "Be not the first by which the new is tried, nor the last to lay the old aside," fits the thinking of the early majority. They follow with deliberate willingness in adopting innovations, but seldom lead.
  • Late majority is the next 34 percent of the individuals in a system to adopt an innovation. The late majority adopt new ideas just after the average member of a system. Like the early majority, the late majority make up one-third of the members of a system. Adoption may be the result of increasing network pressures from peers. Innovations are approached with a skeptical and cautious air, and the late majority do not adopt until most others in their system have done so. The weight of system norms must definitely favor an innovation before the late majority are convinced. The pressure of peers is necessary to motivate adoption. Their relatively scarce resources mean that most of the uncertainty about a new idea must be removed before the late majority feel that it is safe to adopt.
  • Laggards are the last 16 percent of the individuals in a system to adopt an innovation. They possess almost no opinion leadership. Laggards are the most localite in their outlook of all adopter categories; many are near isolates in the social networks of their system. The point of reference for the laggard is the past. Decisions are often made in terms of what has been done previously. Laggards tend to be suspicious of innovations and change agents. Resistance to innovations on the part of laggards may be entirely rational from the laggard's viewpoint, as their resources are limited and they must be certain that a new idea will not fail before they can adopt.

The third way in which time is involved in diffusion is in rate of adoption. The rate of adoption is the relative speed with which an innovation is adopted by members of a social system. The rate of adoption is usually measured as the number of members of the system that adopt the innovation in a given time period (see Figure 2). As shown previously, an innovation's rate of adoption is influenced by the five perceived attributes of an innovation.