National Network of Libraries of Medicine
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December 10, 1997
Everett M. Rogers and Karyn L. Scott
Department of Communication and Journalism
University of New Mexico
Albuquerque, New Mexico 87131-1171
FAX: (505) 277-4206
Draft paper prepared for the National Network of Libraries of Medicine, Pacific Northwest Region, Seattle.
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)
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.
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.
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.
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|
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.
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.
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.
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.
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.
The fourth main element in the diffusion of new ideas is the social system. A social system is defined as a set of interrelated units that are engaged in joint problem-solving to accomplish a common goal. The members or units of a social system may be individuals, informal groups, organizations, and/or subsystems. The social system constitutes a boundary within which an innovation diffuses. How the system's social structure affects diffusion has been studied. A second area of research involved how norms affect diffusion. Norms are the established behavior patterns for the members of a social system. A third area of research has had to do with opinion leadership, the degree to which an individual is able to influence informally other individuals' attitudes or overt behavior in a desired way with relative frequency. A change agent is an individual who attempts to influence clients' innovation-decisions in a direction that is deemed desirable by a change agency. In the present white paper, medical librarians are considered as important change agents in the process of the communication of medical information (see Figure 1). The fourth area of research involves the types of innovation-decisions (whether individual adoption decisions or organizational decisions, and whether they are made by an authority or by consensus). The last area of research has analyzed the consequences of innovation.
A final crucial concept in understanding the nature of the diffusion process is the critical mass, which occurs at the point at which enough individuals have adopted an innovation that the innovation's further rate of adoption becomes self-sustaining (the shaded area in Figure 2 depicts the critical mass). The concept of the critical mass implies that outreach activities should be concentrated on getting the use of the innovation to the point of critical mass. These efforts should be focused on the early adopters, the 13.5 percent of the individuals in the system to adopt an innovation after the innovators have introduced the new idea into the system. Early adopters are often opinion leaders, and serve as role-models for many other members of the social system. Early adopters are instrumental in getting an innovation to the point of critical mass, and hence, in the successful diffusion of an innovation.
What conclusions can be drawn from the Wallingford and others (1996) summary of the 300 outreach projects?
1. Despite the relatively large number of outreach activities by the NLM system, the percent of health care professionals reached by these projects is but a very small part of the total population. Only approximately 20,000 health professionals in the United States (a small percent of the total population) have been reached via the 300 NLM-supported outreach projects. As an example, an NLM-supported Pacific Northwest outreach project reached 5,160 medical practitioners at 190 sites in 304 sessions. The medical practitioners participating in this outreach project represented a very small percent of the total number of health professionals in the Pacific Northwest region. The inadequate scope of outreach activities to date is recognized by Wallingford and others (1996, p. 57): "Outreach will not be completed until every health professional in this country knows about NLM and the information resources it produces and makes available." Clearly, at present the NLM system is very far from reaching this goal. The present strategies of diffusion that are being utilized by the NLM system do not exhibit adequate promise for reaching this goal, in the opinion of the present authors of this report. For example, early adopters and opinion leaders are not currently being targeted by NLM for intensive outreach activities. One obvious strategy for future outreach activities would be to concentrate the relatively intensive and expensive (per health professional reached) outreach efforts on early adopters/opinion leaders, in order to reach critical mass and a self-sustaining diffusion process.
2. Past outreach activities of the NLM system are aimed primarily at the least advantaged segment (the "information poor") of health care professionals, who serve the least advantaged populations in the United States, but the diffusion strategy of targeting the intended audience of early adopters/opinion leaders (so as to achieve critical mass in the diffusion process) has not been utilized in NLM-supported outreach projects. Thus the potential power of the diffusion process to multiply existing resources devoted to outreach has not been realized. Actually, the two strategies are compatible. Future outreach activities could be targeted to the early adopters/opinion leaders among the health care professionals serving disadvantaged members of the public.
Between 1989 and 1994, the majority (84%, n=49) of the GRATEFUL MED demonstration and training efforts took place in rural locations where health professionals practice in relative isolation, often lacking affiliation with an institution that has a medical library (Wallingford and others, 1996). Twelve (21%) of the GRATEFUL MED demonstration and training projects emphasized reaching health professionals who practice in inner-city locations and provide health care services to largely minority and low-income populations. Twenty-four (41%) of the GRATEFUL MED demonstration and training projects focused on minority health professionals and health professionals serving largely minority populations. In a great many of the GRATEFUL MED demonstration and training projects (62%, n=36), group training at the participating sites was the main strategy used. However, twenty-four (41%) of the GRATEFUL MED demonstration and training projects were one-on-one sessions held at the practitioner's office. This outreach strategy is intensive and expensive, per practitioner reached. In seven of these twenty-four projects, the GRATEFUL MED software was installed on the practitioner's computer at the same time (Wallingford and others, 1996).
3. NLM system outreach activities center on promoting the health information resource of the Internet GRATEFUL MED, while largely ignoring other new communication technologies such as e-mail, fax, and so forth, which might be more appropriate in some cases, especially for disadvantaged audiences who cannot presently access the Internet.
Formative evaluation is a type of research that is conducted while an activity, process, or system is ongoing, in order to improve its effectiveness (Rogers, 1995). The Wallingford and others (1996) summary of the 300 outreach projects of the NLM system indicates that relatively few of these projects utilized formative research methodologies to design outreach activities that would be more effective when implemented on a larger scale. One example of a formative evaluation research project, however, was the marketing study to determine medical information needs on the part of intended audiences (Mullaly-Quijas and others, 1994). A questionnaire was distributed to all physicians in five Texas counties, in order to assess their information needs (Bowden, Kromer, and Tobia, 1994). Another formative evaluation approach was the beta testing of the Internet GRATEFUL MED at several hundred sites.
Greater emphasis should be placed on determining the information needs of the intended audience in future evaluation research. As Wallingford and others (1996) stated, "Effective outreach requires a deep understanding of the targeted group or groups and their information needs." Mullaly-Quijas, Ward, & Woelfl (1994) provide an example of using focus groups to discover health professionals' information needs. These researchers discovered that there was little awareness of the National Network of Libraries of Medicine among the health professionals participating in their focus groups. Additionally, librarians were seen by most of the health professionals as an essential link in the information chain from biomedical research to health professionals (see Figure 1). The health professionals of study also cited time3, inaccessibility, and lack of computer skills as the primary barriers to accessing medical information resources.
A second example of determining the information needs of the intended audience is provided by Bowden, Kromer, and Tobia (1994), who assessed physicians' information needs, comparing (1) physicians with access to established medical libraries versus (2) physicians who practiced in remote areas without local access to medical information. Information resource use, particularly reasons for use and non-use of MEDLINE, were explored. More than 40 percent of the physicians in both groups rated themselves as not at all experienced with using computer databases.
Summative evaluation is a type of research that is conducted to reach a decision about the effectiveness of an activity, process, or system after it has run its course (Rogers, 1995). The main purpose of summative evaluation is to form a judgement about the effectiveness of an outreach project, activity, or strategy. The Wallingford and others (1996) summary indicates that very few of the 300 outreach projects of the NLM system were evaluated as to their effectiveness. Summative evaluation research should be a component of every outreach project of the NLM system in order to learn lessons about how to design and implement more effective outreach projects in the future.
The diffusion model suggests that the most important single indicator of effectiveness (defined as the degree to which the implementation of an outreach strategy attains its stated goals) is the rate of adoption of an innovation (like the Internet GRATEFUL MED) by an intended audience (for example, health professionals serving Native Americans in Alaska). Fortunately, new communication technologies like the Internet GRATEFUL MED can provide computer-retrievable data about their use (adoption). Such rate of adoption data can also be obtained from surveys of audience members. Program administrators need to monitor such data in order to measure progress toward providing appropriate medical information resources to health professionals.
|Figure 3. Flow chart of the Diffusion Process for Medical Information Resources in the United States|
Figure 3 shows an input/process/output flow chart for the diffusion of medical information resources to health professionals. Variables are identified that could be measured to indicate the effectiveness of diffusion strategies for increasing the use of medical information by health professionals. The most rigorous evaluation methodologies for determining the relative effectiveness of various diffusion strategies are field experiments. An example is the study by Schaeffner, Ray, Federspiel, and Miller (1983) of different outreach methods for diffusing two innovations (1) elimination of certain antibiotics (that were contraindicated) by medical doctors in Tennessee, and (2) reducing the cost of health care by decreased use of certain expensive oral cephalosporins. Outreach strategies for these two innovations were (1) mailed brochures, (2) an office visit by a drug educator, or (3) an office visit by a senior medical doctor/counselor. A fourth area in Tennessee served as a control. The study's results indicated that the physician/counselor strategy was most effective in securing the adoption of both innovations (it also was the most expensive strategy per professional reached). While the Schaeffner and others' field experiment did not concern the diffusion of medical information resources, its research methodology can easily be translated to this problem.
The two-step flow model highlights the importance of opinion leaders in diffusing innovations, and especially in reaching the critical mass (see Figure 2). Opinion leaders informally influence other individuals' attitudes or overt behavior in a desired way with relative frequency, so they are critical to the successful diffusion of innovations. Rather surprisingly, none of the 300 NLM outreach projects report attempts to target opinion leaders so as to reach the critical mass in the diffusion of the Internet GRATEFUL MED, and other new tools for accessing medical information resources. Early adopters/opinion leaders should be targeted by the NLM in order to multiply relatively expensive one-on-one training and the on-site training sessions for small groups of health professionals.
We live in the age of the communication revolution. New and developing communication technologies, and, ultimately, equipment and systems, are greatly influencing the communication industry and American society. Take the Internet for example. The Internet is a network of interconnected computer systems. By using the Internet as a data highway, an individual can communicate with colleagues and friends at great distance very cheaply, and gain direct access to information in other computer systems. The Internet provides a direct connection to medical information resources that include library catalogs, electronic journals, software, and data-files. Furthermore, diffusion of the Internet has been exceedingly rapid. From 1990 to 1996, the number of individuals adopting the Internet in North America rose from approximately 5 million to 52 million (Figure 4). A huge percentage of the population is interconnected via the Internet. Obviously, the critical mass in the diffusion of the Internet occurred in 1990, after 20 years of very slow increase in the rate of adoption of computer networks.
|Figure 4. The rate of adoption of the Internet and the World Wide Web is increasing very rapidly during the 1990s.|
Most schools and local libraries are connected to the Internet, and can provide Internet access to individuals who otherwise might not own, or have access to, a computer. These organizations can act as intermediaries in diffusing information via computer-mediated communication, thus offering a means to narrow the information gap. The potential for using computer-mediated communication for outreach activities is enormous, and the NLM system has pioneered with the Internet GRATEFUL MED.
Figure 5 shows the present era in the flow of medical information that is characterized (1) by increasing new communication technologies, and (2) by active information-seeking by members of the public.
|Figure 5. Changing patterns in the flows of medical information.|
Further, the NLM system may be able to help equip medical libraries so that they can better serve health professionals in accessing medical information resources, so that the rate of adoption of new communication technologies like the Internet GRATEFUL MED can more quickly reach critical mass (see Figure 2). Critical mass may already have been reached for several computer-related medical information resources. For example, the PSRML survey of hospital libraries in 1994 found that the use of information services associated with computers more than doubled during the previous five years. However, few of the hospital libraries reported any type of outreach service to unaffiliated institutions (see Figure 1).
If the new communication technologies like the Internet GRATEFUL MED can be designed/redesigned to be more user-friendly, a more rapid rate of adoption would probably result.
The present white paper assumes that greater attention to the diffusion of innovations model by the NLM system can improve the effectiveness of outreach activities, especially those devoted to contacting the health care professionals who serve disadvantaged segments of the U.S. population.
1 The information gap (also referred to as the communication effects gap) is that many communication activities have greater effects on those individuals who are socioeconomic elites, compared to those individuals who are less elite (Tichenor and others, 1970).
2 Heterophily is the degree to which two or more individuals who communicate are unalike in characteristics that are relevant to their comminication (Rogers, 1995, p. 18).
3 Dorsch and Landwirth (1993) also found that rural Illinois physicians said that they lacked time to participate in GRATEFUL MED training sessions.
4 Although the research evidence to date shows that there is only a very modest diffusion of practice guidelines (Davis and Taylor-Vaisey, 1997).
5 The process through which practice guidelines are developed, both through the NIH OMAR (Office of Medical Applications of Research (Ferguson, 1995), and more generally (Cook, Greengold, Ellrodt, and Weingarten (1997), have been documented.
D.J. Cook, N.L. Greengold, A.G. Ellrodt, and S.R. Weingarten (1997), "The Relation between Systematic Reviews and Practice Guidelines," Annals of Internal Medicine, 127 (3):210-216.
D.A. Davis and A. Taylor-Vaisey (1997), "Translating Guidelines into Practice," Canadian Medical Association Journal, 157 (4):408-416.
J.L. Dorsch and T.K. Landwirth (1993), "Rural GRATEFUL MED Outreach: Project Results, Impact, and Future Needs," Bulletin of the Medical Library Association, 81 (4):377-382.
J.H. Ferguson (1995), "The NIH Consensus Development Program," Journal of Quality Improvement, 21 (7):332-336.
P. Mullaly-Quijas, D.H. Ward, and N. Woelfl (1994), "Using Focus Groups to Discover Health Professionals' Information Needs: A Regional Marketing Study," Bulletin of the Medical Library Association, 82 (3): 305-311.
S.M. Robinshaw and B.G. Roth (1994), "GRATEFUL MED-LOANSOME DOC Outreach Project in Central Pennsylvania," Bulletin of the Medical Library Association, 82 (2):206-213.
Everett M. Rogers (1995), Diffusion of Innovations (Fourth Edition), New York, Free Press.
William Schaeffner, Wayne A. Ray, Charles F. Federspiel, and William O. Miller (1983), "Improving Antibiotic Prescribing in Office Practice: A Controlled Trial of Three Educational Methods," Journal of the American Medical Association, 250 (13):1728-1732.
Phillip J. Tichenor and others (1970), "Mass Media Flow and Differential Growth in Knowledge," Public Opinion Quarterly, 34:159-170.
K.T. Wallingford, A.B. Ruffin, K.A. Ginter, M.L. Spann, F.E. Johnson, G.A. Dutcher, R. Mehnert, D.L. Nash, J.W. Bridgers, B.J. Lyon, E.R. Siegel, and N.K. Roderer (1996), "Outreach Activities of the National Library of Medicine: A Five-Year Review," Bulletin of the Medical Library Association, 84 (2):1-60.