Author: Bryan P. White
Original Publication: 08/31/2019
Diffusion of innovation is a social theory that describes the process through which new ideas permeate into a community, individual, or organizational unit. This theory is useful in its applications to public health interventions because it allows for the rate at which an idea, or in this case, an intervention strategy, to be quantified experimentally. In this paper I review a community-based intervention for Dengue fever in the La Lisa municipality of Havana, Cuba. The La Lisa municipality is a densely populated area bordering the western region of Havana, making it a high-risk area for infestations of the Dengue mosquito, Aedes aegypti. The researchers (Perez et al., 2010) that conducted this study implemented an innovation of diffusion (ie. fidelity) strategy to track the progress of their intervention over 3 years. Overall, while in some regions of La Lisa adoption and implementation of intervention strategies were successful, in others little to no implementation was seen. The researchers identified several bottlenecks and areas of potential improvement in their diffusion strategy, most of which focused on the complex organizational structure at play in the Cuban governmental system. While there was some success in this strategy, the researchers suggest that future interventions should focus at the education (knowledge & awareness) stage, which specific educational modules designed around improving organizational structures across the hierarchy of Cuban municipality governments and health workers.
Innovation diffusion is a process through which ideas transfer (“diffuse”) from innovators into adopters (Rogers, 2003; Pérez et al., 2010; Glanz et al., 2015). The model, as originally suggested by Rogers (2003) includes 5 key components, or steps, for an idea to diffuse:
1.) Knowledge or Awareness: At this stage an individual is exposed to an idea and gains an awareness of the new concept.
2.) Persuasion: The individual or organizational unit forms an opinion about the concept which can be favorable or unfavorable.
3.) Decision: The individual or organizational unit makes a decision about the concept wherein they either accept (adopt) or reject the concept.
4.) Implementation: The individual or organizational unit puts the innovation to use.
5.) Confirmation: The individual or organizational unit has begun using the innovation and then either reinforces and continues its use or decides to reject and discontinue the use of the innovation.
In order to better understand these concepts, I reviewed a fidelity study by Pérez et al. (2010) of a community-based intervention for Dengue fever in Havana, Cuba. This study took place in the La Lisa municipality of Havana, Cuba. The population of La Lisa was 136,231 as of 2010 (http://www.statoids.com/ycu.html) with an area of 37.5 km2, giving it a population density of of 3,600 people per square kilometer. With a high population density in an urban landscape, this makes the La Lisa municipality a high risk for its occupants encountering mosquitoes (primarily Aedes aegypti) carrying the Dengue fever virus (DENV). In 2015, there were 1,623 confirmed cases of DENV infection in Cuba (https://www.paho.org/salud-en-las-americas-2017/?page_id=111) making the design of public health interventions a critical research area for public health officials, social scientists, and community leaders in the country. Globally, DENV causes up to 25,000 (http://www.eliminatedengue.com/our-research/dengue-fever) deaths annually, and another 390 million apparent infections (Bhatt et al., 2003). In this study, a group of researchers work with local community leaders to design, implement, and track the progress of a DENV intervention program utilizing aspects of a diffusion of innovation theoretical model.
Within the municipality of La Lisa, there exists varying degrees of mosquito exposure risk. The researchers in this study identified and selected three People’s Council’s (PC, a subdivision of government below the municipality level) that were of the greatest risk for A. aegypti infestation (>2% House incidence (HI) rate, meaning >2% of houses had the presence of A. aegypti larvae). PCs typically contain about 30,000 inhabitants, with another subdivision existing below that called the “circumscription” level, which consist of about 1,000 inhabitants. Within the 3 selected PCs (Balcón Arimao, Alturas de La Lisa, and Versalles Coronela), a random subset of 16 circumscriptions were selected to implement the modified DENV control strategy. The remaining circumscriptions would serve as control areas to compare to against the program implementation.
In order to design an effective intervention strategy that would have a high probability of decreasing A. aegypti infestation rates, researchers worked with both the municipality and PC levels of government to develop and manage specific implementations. The development (innovation) stage of the intervention consisted of four parts: organization and management, capacity-building, community work, and surveillance.
While the overall organization and management of the projects occurred at the municipality and PC levels, specific working-group decisions were made at the circumscription level by Community Working-Groups (CWGs). PCs coordinate training for leaders within the CWGs, while CWGs devise and implement specific intervention strategies according to their community needs and operate at the circumscription level. Overall, this component was only implemented in 26.6% of circumscriptions, and modified in 18.7%. This suggested that while there was a presence of a CWG leading the implementation strategy, the actual mobilization of new, external resources was low.
Capacity-building is the process of building education within the organizational structure and community. At the highest levels of management (municipality level), participants were trained on research techniques, A. aegypti management methods, and how to use geographical information systems (GIS). At the CWG level, a series of learning group workshops involving education about participatory diagnosis (understanding what needs to be modified), mosquito surveillance strategies, and evaluation methodologies. Capacity building had a high implementation rate with 54.7% of circumscriptions implementing some form of education promotion, participatory workshop, or surveillance risk education program. Another 17.2% of circumscriptions modified existing strategies.
Community work is the specific set of implementation strategies that were put into place at the CWG level. During the capacity-building phase, CWGs receive guidelines (developed at the PC/municipality level) to implement strategies. At this stage, the CWGs begin actively implementing their strategies, evaluating the results, and working with the inhabitants of the circumscriptions. Of the subcomponents of community work, risk-mapping and problem assessment were the most frequently implemented, with an overall implementation rate of 40% for at least one component of community work. Local communication strategies and the development of communication materials were the least implemented subcomponents. Some of the low implementation rates could have been due to the presence of AaCP staff in CWGs carrying out routine duties outside of the CWG instead of reporting within the CWG.
The surveillance component consists of the interaction of CWGs with the Cuban national Aedes aegypti Control Program (AaCP) to monitor the ongoing environmental risks of A. aegypti infestation. Of the four primary innovation components, surveillance was the highest implemented with a rate of 73%. The domicilary subcomponent of surveillance (indoor house monitoring) was fully implemented in all 16 circumscriptions, but the innovative component involving the identification of behaviors related to A. aegypti infestation risk was only implemented in 37.5% of circumscriptions, suggesting the behavioral aspects of mosquito management were more difficult to influence compared to routine monitoring practices conducted by AaCP staff.
Following the study for 3 years, the researchers conducted an assessment to understand why implementation rates were low in some components of the intervention strategy which included interviewing participants of the study. In some cases, variability in success might have been due to preferences of local governments at the PC and circumscription level. In terms of dissemination strategy, many of the interviewees were unable to offer a comprehensive overview of the entire strategy. During the capacity-building component, many interviewees found the training too theoretical, meaning that the CWG had to spend significant resources to understand and convert theory into actual implementations. Additionally, new, local challenges specific to communities meant that many implementation strategies needed to be modified and adapted throughout the program.
In terms of time investment, many of the participants felt that they had to invest personal time in the implementation strategies, including AaCP staff, meaning that the opportunity cost for helping implementation was very high. In some cases, a lack of support and commitment at various levels of program caused a breakdown of communication, for example, if a decision was needed from a higher level of organization than the WCG (PC or municipality level), project activities had to be halted until a decision-maker could be contacted and meet with the necessary parties. If the relevant parties had significantly diverging priorities, they might have arrived at an impasse which would ultimately influence implementation rates. Furthermore, in some cases, the CWG level was never properly integrated with higher-level management and/or AaCP staff that could carry out specific implementations. On the other hand, in many cases CWGs might have been awaiting financial support from PC or municipality level organizations, which in turn would have also delayed or eliminated the actual implementation of program goals.
Overall this study noted low implementation results, which the source of which seems to be at the CWG implementation level. One of the suggested modifications to the program is that during the capacity-building phase there needs to be a specific education module related to organizational structure – since governments and health workers are frequently a “moving target” (ie. promotions, transfers, and restructuring occurs routinely), the CWGs need a system for maintaining functionality in the face of an ever transitioning organizational structure. In terms of innovation diffusion, this study found a failure at the information dissemination stage – educational and intervention strategies were not introduced to the correct parties due to a breakdown of organizational structure. This conclusion suggests that following up and monitoring the diffusion process more frequently should be an important part of these types of strategies so that any breakdowns in the diffusion system can be identified and modified early on in the process.
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