Volume 5, Issue C ::: February 2002
Diffusion of Innovation
Health teams are often put together by literacy programs that run literacy and health projects; for a report on one such team, see the article on page 30. These teams of self-selected participants explore health issues and then teach their friends and neighbors what they have learned.
The underlying literacy assumption in this model is that using literacy skills for purposes outside the classroom enhances motivation and learning. The underlying theoretical assumption is that change is promoted through ideas or information introduced by people with whom you can identify. This assumption is supported by a model called diffusion of innovation. This model is very useful in helping us answer two critical questions: How do ideas spread among a group of people over time? How can we speed up this process?
The diffusion of innovation model offers a lens through which we can better understand the growing interest in literacy within the health field. It might also help us shape a strategy to speed up the diffusion process: to build further interest as well as to design health literacy programs. This model is well over a hundred years old and comes out of agricultural extension, anthropology, and sociology. It has been most recently defined by Everett Rogers (1995), a communications expert and academic, who began his studies with an examination of how new agricultural techniques spread in a farming community.
The diffusion of innovation model describes the way an idea or product enters a social system and is "adopted' by groups of people within that system. For example, findings from the National Adult Literacy Survey (NALS) were published in 1993 and disseminated within the education field and among policy-makers focused on education. These findings began to spread slowly into other fields. A small but growing group of health researchers and practitioners recognized the importance of these finding and began to conduct research studies linking health to literacy skills. Others among them created educational presentations and training programs for their colleagues. Health literacy is now included in the goals and objectives for the nation in Healthy People 2010. In addition, functional literacy tasks related to health will be included in the National Assessment of Adult Literacy Survey (NAALS) scheduled for 2002. At the same time, however, the findings from 1993 and the work that followed are still news to many researchers, practitioners, and policy-makers in medicine and public health. The dissemination efforts must continue.
How would we describe this diffusion process thus far? What helped it along? The diffusion of innovation model reminds us that the diffusion and change process is often gradual and depends on a number of key factors: the characteristics of the innovation itself, the social system within which the innovation is introduced, the available channels of communication, and the change agents who help spread the idea.
An innovation is defined as something new to the people to whom it is being introduced. In our discussion, the innovation is the awareness of possible links between literacy and health. This innovation is complex because it requires knowledge about the NALS survey and NALS findings as well as the implications for health action. Because the NALS findings were perceived as an education issue, the characteristics of this innovation hindered rather than helped its diffusion among people in the health fields.
The Social System
The diffusion model informs us that the spread of information or ideas is influenced by the social system. The health field is a complex system comprised of many different professional groups. Each group identifies with its own discipline: public health, medicine, nursing, and so on. And, of course, there are subspecialties within each group.
In addition, the social systems in health and medicine are hierarchical. For example, medicine tends to have more political clout than does public health. The letters following a researcher's name have layers of subtle influence. And, finally, more attention is drawn to research findings in medicine than in other health fields such as nursing, considered a lower-status field.
Channels of Communication
New information related to health is diffused through professional peer-reviewed journals and face-to-face at meetings. However, each discipline has its own journals. Nutritionists, epidemiologists, health educators, medical doctors, hospital administrators, and public health program specialists may all read different journals. Contemporary professionals struggle to keep up with publications in their own field, let alone any others. As a result, professionals do not necessarily read research published in other fields. In addition, public health epidemiologists, for example, tend not to go to the same professional conferences as public health educators or public health nurses. Generally, doctors and nurses do not attend the same meetings and do not take part in the same professional education courses. On the surface, the limited channels of communications - journals, professional meetings - makes it appear that the communication process could be easy, but the multiple layers of professional groups within the health field slow down the diffusion process.
Change Agents and Channels of Communication
The diffusion model informs us that information and ideas are best transferred by people like those to whom the new ideas are being introduced. Health educators and nurses, perhaps because they were most closely linked to the education field and are often responsible for patient education, became aware of the NALS early. Many of the first studies related to literacy and health were published in nursing and health education journals and were often focused on examinations of the many pamphlets, informational booklets, and directions used with patients. Most of the studies published in the 1980s and throughout the 1990s were concerned with assessments of materials. More than 200 studies found these materials to be inappropriately written, often at reading grade levels above high school. Professionals from other health fields did not necessarily know about this body of evidence.
In the early to mid-1990s, a few researchers at medical centers and schools began think about patients' ability to comprehend medical instructions. Study findings, written or coauthored by medical doctors and published in medical journals, were more likely to be read by other doctors. Therefore, the attention of doctors and researchers increased with the publication of about a dozen studies examining the association between low literacy and medication-taking, disease management, and hospitalization. A White Paper on health and literacy published in 1999 in the prestigious Journal of the American Medical Association increased awareness among doctors and medical researchers of the potential health consequences of limited literacy.
Rogers also notes that reinvention is part of the diffusion process. As awareness of health and literacy links were disseminated, researchers and practitioners in public health began to expand the definition of health literacy. The idea that health literacy should be defined and measured by what takes place within the doctor's office or within an institutional setting is slowly being replaced by a broader vision that incorporates health promotion and health protection activities that take place where people live and work. Some of these will be included in the 2002 national assessment of adult literacy noted earlier. It will include functional literacy tasks such as finding information in a health article, an insurance plan, or a food label. This broader notion of functional health literacy calls for an additional set of skills related to fact-finding, decision-making, participation, and advocacy. Many of these skills are rooted in a sense of efficacy both for individuals and for people working in groups. This brings us full circle back to the health team activities noted earlier.
The health team activities and several other examples of innovative practices in adult education can be enhanced or developed through insight from the diffusion of innovation model. The diffusion model supports good curriculum planning. It encourages us to think about what topics and skills are most needed by and fit into the interests of the students, how new ideas and skills are best introduced, what kinds of activities best support learning and adoption, and what activities would best support the further diffusion of ideas and skills beyond the classroom.
Research tells us that the strongest channel of communication is face to face. Of course, the education system is based on this powerful communication channel. Within the adult education classroom, teachers are in the best position to introduce new ideas. They serve well as change agents because of the close contact they have with their students and because they are often well trusted by their students. The educator introducing new ideas and skills to adult learners is a diffusion process. How might this setting support a much wider diffusion effort?
If adult learners are viewed as possible change agents in their own communities, then lessons can be shaped to help them develop the needed skills to become change agents. Their work in class can increase their reading skills, vocabulary, inquiry skills, ability to read and understand charts, ability to fill out forms, and, of course, their knowledge base. This class work combined with practice opportunities and assignments that take them outside the classroom can enhance their ability to engage with and perhaps teach others. Materials used in class can, if shared with these adult learners, provide them with the tools needed to reach out to others in their family, at work, and in the community. Organized teamwork and opportunities to help others enhance a sense of efficacy and support change as well as the diffusion process
How else might this model shape future efforts? Increased health literacy must involve educators as well as health professionals. We know that adult educators are more likely to adopt materials developed by experts in their field. Health professionals are likewise more apt to attend to and approve of processes and materials developed by health professionals. Thus, program design must involve partnerships involving professionals from both fields. Furthermore, if educators and health professionals conduct studies and publish together, these results are more likely to draw the attention of researchers in both fields.
Rogers, E.M. (1995). Diffusion of Innovations. New York: The Free Press.
Many health education textbooks offer discussions of different social and behavioral theories. A small handbook for practitioners offers a good start:
Glanz, K., & Rimer, B.K. (1995). Theory at a Glance: A Guide for Health Promotion Practice. Maryland: US Department of Health and Human Services. National Cancer Institute (NCI). NIH Publication No. 95-3896.