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Diffusion of Innovations Theory, Principles, and Practice
Diffusion of Innovations Theory, Principles, and Practice
I
n synthesizing many studies from differ- series of developmental, demonstration, and
ent disciplines about how people re- evaluation grants from the Robert Wood John-
spond to new ideas, Everett Rogers son Foundation beginning in 2003, more than
was answering a call set forth by the 200 Green Houses were in operation across the
sociologist Robert K. Merton: theorize, US in 2017 with 300 expected by the end of 2018.6
but in empirical ways and with practical impli- Project ECHO and the Green House model
cations.1 Now, fifty-six years past the first are evidence-based innovations that are spread-
publication of Rogers’s book Diffusion of Innova- ing as new ways to deliver health care, but have
tions, we briefly review this theory, its principles, they diffused? To assess the diffusion of an inno-
and the implications for practice as a fifteen-year vation, one must attend to its denominator. In
update to the book’s last edition in 2003. these examples, the number of plausible and
One of the best documented if frustrating prin- potential adopting sites for either of them is
ciples of diffusion is that it can take a long time. large, with 4,134 Medicare-certified rural health
Consider the case of Project ECHO (Extension clinics in 2015 and 15,583 certified nursing
for Community Healthcare Outcomes), previ- facilities in the US in 2016.7 In diffusion terms,
ously reported in Health Affairs.2 This innovation even after fourteen years and like many other
in how academic medical centers partner with health care innovations, impressive innovations
rural primary care clinicians to extend specialty such as Project ECHO and the Green House mod-
care began at one site in New Mexico in 2003. el still have not reached “takeoff” or a tipping
By November 2017 Project ECHO reported 158 point in time on a national diffusion curve.8
sites across the US, with sixty more sites in twen-
ty-four other countries.3 The program has moved
from hepatitis C care to include HIV/AIDS, geri- What Is Diffusion?
atrics, psychiatric medication management, and Diffusion is a social process that occurs among
more.4 Or consider the Green House model of people in response to learning about an innova-
nursing home care, in which “house-like” facili- tion such as a new evidence-based approach for
ties are built that emphasize an open kitchen, extending or improving health care. In its classi-
residents’ control in decision making, and em- cal formulation, diffusion involves an innova-
powered nursing assistants.5 Underwritten by a tion that is communicated through certain chan-
nels over time among the members of a social sion to reject an innovation socially confirmed.12
system.9 The typical dependent variable in In the case of voluntary adoption decisions,
diffusion research is time of adoption, though acceleration in the rate of diffusion is usually
when complex organizations are the adopters, the result of influential members of the social
subsequent implementation is a more meaning- system making the decision to adopt and their
ful measure of change. Diffusion can be assessed decision being communicated to others, who
among individuals such as members of Con- then follow their lead. To use the example of
gress, organizations such as health care insur- efforts to reduce tobacco use, while a small sub-
ers, or larger collectivities such as cities and set of tobacco taxation policy experts, child wel-
states. Exhibit 1 illustrates the relationships be- fare specialists, or mayors may make careful as-
tween rates of adoption and how we characterize sessments of the evidence and other attributes of
diffusion under different scenarios, including an innovation, most of their eventually adopting
when innovations are introduced and do not dif- peers do not. When opinion-leading individuals
fuse. When time-of-adoption data are graphed and organizations adopt an innovation, social
cumulatively, an S-shaped curve is common, systems convert from one normative state (such
with an initial slow rate of adoption giving way as smoking in public being acceptable) to anoth-
to a rapidly accelerating rate, which then slows er (smoking being unacceptable).When opinion
as fewer nonadopters remain within the social leaders do not adopt an innovation, systems do
system in question. Not all instances of diffusion not change. Diffusion is an atypical outcome,
play out this way, especially in policy diffusion— since the vast majority of innovations fail to dif-
where time to adoption can be shorter because of fuse, never accelerating up an S-shaped curve.13,14
the occasional convergence of national attention This can be a wholly warranted result, since an
to a problem, financial incentives, readiness for innovation is defined simply as that which is
change among elected officials, motivated and perceived to be new—not necessarily better—
organized groups, and an innovative solution by potential adopters. Unworthy innovations
that is perceived positively.10 sometimes diffuse, and effective innovations
As exhibit 1 suggests, several contextual as- are often stymied.
pects of diffusion typically go unstudied. Com- Over time through waves of innovations,
peting or complementary innovations are impor- diffusion changes societies. Sometimes these
tant, since potential adopters usually have a changes manifest as differences in knowledge,
choice in what to adopt. Failures are important, disproportionate access to government and com-
since most innovations do not diffuse. Decelera- mercial services, and worsening inequality be-
tion is important in two ways, since the decision cause resource-rich communities tend to adopt
to adopt an innovation often means abandoning innovations early relative to poor communities.15
a prior one,11 and nonadopters have their deci- In this special issue of Health Affairs, for exam-
Exhibit 1
SOURCE Authors’ analysis. NOTE Each curve represents a separate hypothetical innovation.
NOTES
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