“Diffusion of innovations is a theory that describes how new ideas, opinions and behaviors spread throughout a community.”(Valente, p.34) In this paper I will show how this theory was applied in the reproductive health campaign in Bolivia.
Diffusion theory is used to study the way in which new information is spread throughout a certain population and how innovation is adopted. To begin with, there are five stages in the adoption process:
The first stage is awareness of the innovation – in the case of the Bolivia campaign it is the introduction of family planning. People have to become aware of the new idea and the diffusion of this idea takes more or less time according to the media used to spread it through the population. Usually the mass media are used to spread awareness but it can also be done through primary social networks, i.e. word-of-mouth.
The next stage is persuasion. After people become aware of the new practice they have to be able to learn more about it in order to potentially develop a positive attitude towards it. Different persuasion strategies are adopted according to the sub-population that is targeted. The goal is for this population to accept the new idea as a solution to an existing problem.
Persuasion then makes possible the third step, the decision. Individuals will then make a conscious decision to try a new behavior. This is a vital step in behavior change as is represents a transition from conception of an idea, acceptance of the idea to motivation to take action.
The fourth stage is the implementation of the behavior. The stage represents a transition from processes that are uniquely cognitive to processes that are behavioral. This is therefore the most significant stage in behavior change. The cognitive processes that proceed this stage provide the population with the means to practice/implement the new behavior that had hitherto been advocated.
The last stage is behavior confirmation, the behavior is reinforced and consolidated in order to prevent wearing away of the behavioral practice brought about thus far by persuasive communication. The behavioral act thus becomes incorporated into the cognitive framework, i.e. the normal way of doing things.
The adoption of behavior is influenced by different types of perception, by the “radicality” of the innovation and also by individual characteristics such as education or income. Valente also categorizes individuals within a community according to the time (sequential stage) of their adoption of the new behavior: innovators, early adopters, the early majority, the late majority and the followers (Valente, p.35). The diffusion curve shows that in the beginning of a campaign, the number of people adopting the new behavior is small but increases rapidly until it reaches approximately half of the population, and then slows down as few “non-adopters” are left.
Finally, he shows that the spread of knowledge, positive attitude and practice of the behavior varies in time. Awareness spreads rapidly, faster than attitude and practice, indicating a time lag between knowledge and practice. Aldo he shows how the change in behavior is faster when promoted by a media campaign as opposed to word-of-mouth communication (Valente, p.38).
Limitations of the Theory:
Valente mentions three limitations to the use of diffusion theory.
The first limitation concerns the fact that the promotion of a particular behavior does not occur from the very beginning of a campaign but rather later when a number of people have adopted the behavior and the campaign increases their number.
The second limitation mentioned is the description of the five stages leading to the adoption of the new behavior. He considers their description to be superfluous since awareness, attitude, decision and adoption have to occur in a logical order. For instance: “Individuals have to know about an innovation before they can form an attitude about it and have to feel positively about it before they are willing to try.” (Valente, p.39-40)
Third, Valente mentions several campaigns where the knowledge-attitude-practice model wasn’t used. Instead five other variations of this sequence were observed: KPA, AKP, APK, PAK and PKA. (Valente, p.40)
The reproductive health campaign in Bolivia:
The strong pronatalist policy implemented by the Bolivian government, maintained until 1987, created a number of problems such as infant mortality, maternal death due to abortion and childbirth complications or unwanted fertility. Because of this policy, Bolivian population had no access to either information about or methods of contraception. (p. 98)
In 1987, this policy was reversed and contraceptive methods were introduced in the country again. In 1989 was created the National Reproductive Health Program (NRHP), designed for “the prevention of unwanted pregnancies and the care and treatment of infants and mothers after childbirth” but included also “STD’s, HIV/AIDS transmission and contraceptive use” (Valente and Saba, p. 97, 120). In the same time, the government allowed international organizations and nongovernmental agencies to help implement the new program.
A 1989 survey (DHS, 1994), showed that a vast majority of Bolivian women wanted to have less children. Nevertheless family planning being a controversial subject in Bolivia, it was integrated in the reproductive health campaign, the latter being perceived by the population as an effort on behalf of the government to reduce maternal and infant mortality. (Valente and Saba, p.98) Thus the message was more likely to be accepted by the population and receive a stronger political support from the government.
Reproductive health services being now made available in Bolivia, the campaign was designed to inform the population as to where to obtain them, and improve education concerning reproductive health in general.
The campaign itself began in 1991 with the creation of a NRHP logo that was associated with the health materials newly created and made available to the population a year later together with training activities.
The next stage was the promotion of services through mass media after the development of a distribution strategy and campaign themes. The mass media campaign was conducted trough television and radio spots. Bolivia’s president and the secretary of health were closely associated to the campaign and the latter appeared in one of the television spots. (Valente and Saba, p.103) A total of eleven spots were broadcasted twice: the first time in 1994 over a period of seven months and the second time a year later, in 1995 over a shorter period of three months.
The campaign strategy varied according to the media that were used to broadcast it (television, radio, local or national stations), as well as according to the cultural differences present in the population (for instance, the translation of radio spots into indigenous languages).
In previous studies (Valente and Saba, p. 99) it was argued that mass media and interpersonal communication have different roles in a campaign and affect the targeted population in different ways. On one hand, mass media is a better means to spread information and is used primarily by “opinion leaders” or, as we have seen it in the description of the diffusion of innovation theory, those who are placed in the category of “early adopters”. (Valente, p.35)
Opinion leaders or early adopters of the new behavior are people with higher income and education. On the other hand, interpersonal communication or word-of-mouth communication is used to spread information from the “pioneers” to the late majority. Also interpersonal communication is seen as instrumental in the adoption of the new behavior the campaign is designed to introduce. According to these principles, during the campaign in Bolivia the broadcasting strategy took into account the media used as well as the cultural characteristics of the audience. (Valente and Saba, p. 100)
In this study of the mass media campaign on reproductive health in Bolivia, Valente and Saba use diffusion of innovation in order to “specify the behavior change steps and reproductive health indicators expected to be influenced by the mass media campaign. (Valente and Saba, p. 100) The considered behavior change steps were: awareness, detailed knowledge, attitudes, intention, interpersonal communication, and the family planning method used. (Valente and Saba, p. 96) The object of the study was to “determine how well a specific media campaign disseminated information about reproductive health and whether the campaign influenced the adoption of contraceptives. (Valente and Saba, p. 100)
Three hypotheses are considered in the study (Valente and Saba, p.101 -102):
“H1: Campaign exposure will be associated with increase in awareness of, knowledge of, attitude toward, and intention to practice contraception.
H2: Personal network exposure will be associated with increases in the six steps to behavior change […].
H3: The multiplicative influence (interaction) of campaign and personal network exposure will be positively associated with the steps to behavior change.”
The propositions tested, as mentioned above, were that mass media would influence only the first steps towards behavior change (i.e. awareness and knowledge) whereas personal networks would be essential for the actual adoption of behavior, in this case the use of contraception.
Analysis of the data showed that the influence of the media campaign didn’t have the same effect on individuals according to their personal network. Individuals whose personal network had a high percentage of adopters of the innovation were less influenced by the media than those whose personal network had a lower percentage of innovators.
From this the authors draw the conclusion that individuals who cannot heavily rely on interpersonal communication to obtain information about an innovation will be more dependent on the mass media and will turn to it in order to familiarize themselves with the new information. (Valente and Saba, p. 116) Thus, the mass media campaign had for effect not only to introduce and spread new information but also to play an important role for individuals who were unable to rely on personal networks for knowledge, persuasion and reassurance: “the mass media may substitute for personal network influences and speed social change by accelerating the behavior change process.” (Valente and Saba, p. 96)
As mentioned in the description of diffusion of innovations, several limitations of the theory were mentioned by Valente. One of them was the difficulty to estimate when behavior change occurs and thus the challenge of collecting accurate data about behavior change. In the campaign in Bolivia, this was not the case since the campaign was broadcasted twice and allowed an accurate campaign evaluation.
The use of diffusion of innovation in the evaluation of this campaign helps to explain how the intervention, meant to introduce the use of contraceptive methods and the use of health services in a developing country like Bolivia, is expected to change the populations behavior regarding reproductive health. The theory constitutes here not only an important tool for the conception of the campaign but insures, or at least multiplies the chances, that the campaign will attain its goal.
In Bolivia, the reproductive health campaign was designed to reverse the negative consequences of a strong pronatalist policy maintained for a long time by the government. In order to change the situation, first information had to be brought to the public, then their attitude had to be changed, the new behavior introduced and finally reinforced. Diffusion of innovation perfectly describes how such a campaign would be able to spread the new information, change the public’s opinion and establish the use of contraception as normative.