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[Announcer] This podcast is presented by the Centers for Disease Control and Prevention. CDC – safer, healthier people.

[Jim Dearing] This is one distinguishing feature of meeting at the CDC. I don’t know why it is the case, perhaps my colleague Ed Maibach does, but every time I’ve been in a meeting or given a talk at the CDC, the room is full and I know it has nothing to do with whatever it is I’m talking about. I think there is a tremendous agreement among folks at the CDC that they love to learn new things. That’s my only explanation for this, Ed.

[Ed Maibach] That works for me, let’s stick with it.

[Jim Dearing] We’re going to jointly give a presentation, partly based on a paper that we had published in the American Journal of Preventive Medicine, some copies of which are on a side table over here. We jointly authored, along with David Buller, one of the articles in that special issue about dissemination and diffusion research. Please pick up a copy if you’re interested. There are other articles, more theoretically informed than ours and more practice informed also that are in that issue. If we run out of copies and you want one, write to me and I’ll send you a copy of the journal.

A couple of words very quickly. I work at Kaiser Permanente. This is the nation’s largest non-profit healthcare organization. I work in Denver and my colleague, Russ Glasgow, and I are just in the throws of founding what we call a Center for Health Dissemination and Implementation Research, and so our interest is in studying how to make effective programs, efficacious and effective programs, externally valid. That is, to work in more than one site - second or third generation sites - and then, how to take them, what you might say, to scale - how to disseminate more broadly. Ed Maibach is the Director and I’m going to read this because this title of your Center is as ungainly as is ours - The Center of Excellence in Climate Change Communication Research or CECCR. You’ve got a better acronym than we do. He’s going to play this role this morning. I had a lot of coffee this morning, so only Jude McDivett knows which cups I had were decaf and which were caffeine. Okay Ed, I think you can go ahead. Why did we and why do we believe that certain concepts from social marketing and from diffusion of innovations work well together, Ed? See this is what my mentor did for me. He asks a difficult question to set up the student next to him or the colleague next to him and then of course hands off the difficult answer to the other person.

[Ed Maibach] Okay. Jim is clearly riding off the range here. This is not my understanding of how we were going to do this, but that’s okay. I am clearly willing to play on any terms. As Jim said, we, while both of us study theoretical issues and theoretically informed issues, both of us share a common concern with practice and truly believe that both social marketing, which is not a theory per se but a practice, as well as diffusion theory have enormous practical implications for getting evidence-based programs into use in the field in the settings where they are and most needed. And so, we joined forces with Dave Buller last, really over the course of last year, to write a paper, which we would love to share with you all, and the upshot of the paper were ten interrelated set of principles or practices that we would like to share with you.

[Jim Dearing] One key distinction in my mind and I think in Ed’s mind about assumptions of these two different approaches and a key difference that becomes a commonality when one combines these approaches is that with diffusion scholarship, with diffusion research, there has long been a relational focus. That is, when you look at the set of potential adopters who you might be targeting, often times there’s a focus on the relationships among those different units. Conversely, with a classical marketing perspective, there is an assumption that one can target, one can identify, one can closely ascertain commonalities, based on psychographics or demographics, commonality, and place and target on such factors. And this is a targeting difference in assumption. Another type of assumption relates to what Ed would call and other of you would call a transactional approach of marketing that one conceptualizes the potential adopters - the consumers - as engaging in the transaction. That is the cognitive and the behavioral change that they possibly would make. Diffusion research has not conceptualized a transaction per se, but rather one more of what I would call social influence. One reacts, at least for the majority of potential adopters, based on what others do. One of the, part of the essence of the article that we wrote and of this perspective we have is that one can profitably, as a social marketeer, a practitioner, or a researcher or a social change researcher, one can profitably focus on what we call a societal sector. This is nothing new. If you are steeped in marketing research or in marketing practice, this is old hat to think of influencing people or types of organizations based on commonalities that they share and to convince you that this is nothing new to a marketing group, it’s quite new to many behavioral change researchers, but not to marketing researchers. I’m going to ask Ed to forward this slide to this little diagram which simply attempts to clarify three different concepts - one that we call an organizational field, one that we call an ecological community, and one that we call a societal sector. So, in simple terms, an organizational field simply is a focus on one organization, a focal organization, St. Joseph’s Hospital in Denver, and key suppliers, distributors, audiences - stake holders - important to that one organization. If one then agglomerates similar types of organizations within the same geographic area, that is what we and others, sociologists primarily, call an ecological field. Very complex set of relationships among similar types, functionally similar types of organizations with their key stake holders, all within a common geographic area - in Denver, in Huntsville. This is nothing radically new. Our take on these different ways of slicing audiences or segments is that there’s a third way possible, which we call a societal sector and this is what’s common to marketers, of course. That is that you identify particular types of individuals across organizational fields and across ecological communities - across different cities, across different towns - so physical activity coaches in health clubs across the western United States. Right? This is simple, in a way - target marketing. Our approach usually is one of focusing upstream, not on the ultimate consumer, although we do that sometimes, but focusing on service providers of the ultimate consumer. Anything to add?

[Ed Maibach] Well, this illustration is clearly an illustration of how one would think about an ecological community for physical – evidence-based - physical activity programs, but the idea holds true regardless of what area, or what public health issue we are attempting to disseminate evidence-based programming for. So, if HIV prevention, same thing, different kinds of communities, but the interrelationship among those communities in the larger social sector is really the point that we want you to think about here.

[Jim Dearing] Again, I think this perspective is old hat to experienced marketeers. You’re focusing on people who we’d say are homopholous, functionally homopholous. They have certain commonalities, they’re in certain types of positions, they have common information sources, and of course thus, that’s an efficiency that you can tap into as a marketeer to reach them, right? You have information channels that they attend to and the way that we combine, and I think if there was a contribution to the piece we wrote, it is that we combine that typical marketing focus on a societal sector. A set of common, but geographically dispersed persons in organizations with the study of relationships among those people, which is the basic diffusion approach to trying to formatively understand the structure of a set of relationships among your target audience to use that structure, to tap into it, to piggy back on it for your purpose of social change. And this is the point I just was trying to make I think. That is, that there is an existing structure already in place. Leslie Snyder is nodding her head up here; she knows this from years ago. There is an existing structure, that is, relationships, patterned over time among people you might want to target. So, those exercise coaches in health clubs, they go to the same types of conferences, often times. They go in training sessions for the same types of physical activity promotion programs. Thus, they talk, they get to know each other, some of them, and some of them become relatively more important than others as sources of advice. Ed, how about if we go to…

[Ed Maibach] That one?

[Jim Dearing] Nope, nope, nope. That’s why I didn’t want to be responsible for the clicker. You all know what a sociogram or an communigram looks like. This one is based on data derived from questions in the state of Pennsylvania about advice seeking. Who do you ask for advice on a particular topic? Any social network analysis program, just about any of the fifty or so that are commercially and otherwise available, can now plot sociograms about like this. The simple point to make is that this shows you one particular view of an advice structure. That is, the units are not equivalent, right? They’re related to each other in certain ways or not related to each other in certain ways. The lesson again, a simple one, if you start your campaign, let’s say in the center, which, in general in a sociogram like this, is clustered, based on how many connections - that is, how many of the respondents to your survey have named certain other people who are then graphed centrally as sources of advice - the attitudes, the behaviors that you’re attempting to spread, will be considered and potentially spread more rapidly throughout a societal sector, a social sector, than if you start on the periphery somewhere. Also, there are reputations and statuses associated with the individuals represented by the dots on this sociogram. What that means is that often times we don’t know what the structure is of relationships among a set of people in a network like this. We don’t, we might know the dots, right? We know who’s in the audience, but we have no idea about the lines between the dots. And if you don’t know who’s connected to whom and who asks advice of others within such a system, it’s quite possible you start out on a periphery, often times then, people who are more socially inclined, more available, more trusted, more expert, will look at the innovations being tried, and this is usually where innovations are tried out, on the periphery by wacky people we would call innovators, useful and wacky, they are different, there’s no doubt about it. And the status of those very earliest users gets associated with the innovations. Thus, the people more important to accelerated change will reject the innovation, often times, based on the status associated with these folks. Something, again, that a marketeer knows well.

[Ed Maibach] I just love that diagram. These are actually people, I don’t know if you said this Jim, in the Juvenile Justice System in the state of Pennsylvania, so if you think about the Juvenile Justice System in Pennsylvania I mean, look at this diagram. I mean, who do you want to speak to? Who do you want to become your allies? It’s so achingly obvious. So the third idea that we wanted to present to you this morning is the whole notion of identifying sort of natural distribution channels. We know we need to build. We’re trying to get evidence-based products out into the market place. We know we need to build a supply chain that reaches all the way from our basic R & D function, which is many of you in this room, all the way to the people, the members of the population that we are most concerned about - the people who we are developing programs to benefit and that; so clearly we’ve got to build a supply chain. It’s not something we’re naturally familiar with or highly experienced with in public health. It’s something that our commercial marketing colleagues are all too familiar with. This is really almost their sole obsession, more than anything else, is building a really functional supply chain. And one way that we are encouraging members of the public health community to think about this is building - piggy backing - on existing relationships or established distribution partnerships of other types. So if I were to go back to, very quickly back to this, you can begin to think about within both distribution of supply chains that work across geographic communities, as well as within the geographic community.

An example of this that I think is quite nice is a program currently being conducted in New Jersey. It’s called the New Jersey Mayor’s Wellness Campaign. It’s being run by the New Jersey Healthcare Quality Institute. They have designed what they consider to be sort of an evidence-based tool kit to promote health promotion programming in communities across New Jersey. The way they have built a distribution channel is the Healthcare Quality Institute is working with the mayor’s and municipal health task forces in New Jersey. These are organizations that are essentially being created within individual municipalities that have direct relationships because it’s the mayor and the people that the mayor is bringing together to build the distribution channel for this evidence-based tool kit. The natural distribution channels or partners are employers in the community, principals in the community, other organizational managers, both in terms of reaching older adults in the community, as well as managers of other community organizations targeting, serving the needs of other audiences. So, to the extent that this task force is able to build relationships with senior people in each of these sectors, each of them have natural relationships intact already in which they can essentially recommend and assist the process of the implementation of the tools in this tool kit. This is something that I wrote up, wrote up in another article last, I guess it was published this year. I’m very eager to see some evaluation data. They tell me the process, from a perceptual standpoint, this is going really well. They feel that this is a viable distribution mechanism. The supply chain that they conceptualized is working. Outcomes have yet to be determined.

Another principle that we would like you to consider is differentiating the roles of people in complex organizations. This is a really important point. Even small organizations have complexity to them. Large organizations have vastly more complexity to them. We have to grapple with the fact that the people who decide to adopt an evidence-based practice may not be the ones who are expected to actually use it or apply it. It’s a different part of the management structure and so if we successfully sell or persuade the adopters, the deciders within an organization, to implement, to purchase, however you want to say it, but we fail to attend to the needs of the people who have to implement the program, it’s likely to be more or less dead on arrival. And if that’s not a waste of resources, I don’t know what is, and if nothing else, it will likely burn us the next time out because the decider will no longer be interested in trying out our programs, our evidence-based programming, because last time they did, their people weren’t willing to implement. So we think it’s extremely important from a dissemination perspective to differentiate these two roles, to acknowledge that they will be making decisions based on different sets of information and that while, perhaps from a distribution channel, we need to find the opinion leaders in the social, the ecological system itself. In terms of actually succeeding within an organization, we need to identify the opinion leaders in that organization and enable them to use their innate influence to help ‘grease the skids’ if you will, for successful implementation within that organization.

[Jim Dearing] I’m working with Andrea Dunn, a researcher who some of you would know in physical activity promotion, and Andrea is the PI on a current award from the National Heart, Lung, and Blood Institute to study the implementation of one particular evidence-based physical activity promotion program - a lifestyle physical activity promotion program - and our initial data, preliminary data, about implementation is quite clear that authority figures, opinion leaders, and internal champions all within the same types of organizations, businesses, non-profits, community-based organizations, are functionally distinct roles. They’re different people. So, sometimes we have authority figures - a Vice President, a manager - who also is an opinion leader, but typically that is not the case. We find it erroneous to make the assumption that the authority leader, the sponsor, is also going to be informally influential. They tend to be functionally different people. Same thing with internal champions. The folks we find who get most excited about this lifestyle physical activity promotion program, who really train others in how to use it, who go to the training sessions and talk about it a lot, they can be the folks on the peripheries, internally, within their organization of a social network. So they don’t have the informal influence. Even though they have the expertise about the program, they can tell you how to implement it in the classroom, how to best keep track of enrollees, etc. They have the answers, but often times when people seek advice from others, this was represented well in a recent Harvard business school article. We will take advice more readily from, I’m trying to get this right, the lovable fools rather than the confident jerks. I was looking at Ed. Implementation support is something we find increasingly important. It’s always been important. Increasing in importance only because we’ve been late to the game. You would already know this, I think. Let me just mention quickly that we find it very advantageous to identify networks among practitioners whose behavior we’re trying to modify and then to facilitate information exchange among them. And more specifically, advice exchange among them, through online implementation support systems. So these are very much like normal websites, except the content on these simple websites are all examples from opinion leaders drawn from that practice group about how they have implemented particular aspects of an evidence-based program or practice. That’s it. It’s the whole focus of the website. It’s not a promotional purpose. It’s not a purpose of convincing them to take up the program. The point is to show most potential, actually most prior adopters how it’s working in practices that they respect. How many did Ed say, ten right? Just ten, okay. Another point that you don’t need to be convinced about: people change programs. People change practices and thus the term ‘adopters’ while it may be true, especially when adopters are not users of particular innovations, it’s a misnomer. They’re really adapters, right? They take practices even before people adopt innovations, usually they engage in some form of prospective evaluation. How is this going to work within our organization and they’ll adapt right at the point prior to adoption occurring. So, it helps to anticipate user activity. It also helps a diffusion effort, both adoption and implementation if one encourages adaptation, not just any old adaptation of course, but some form of guided adaptation, responsible adaptation. Point seven, this is the point I just made: design to invite. We believe there is a strong case to be made that the best adaptation will occur at the point of the user, at the point of the implementer for a given best practice or an evidence-based program. Thus, to design ways in to an implementation support system to help them adapt responsibly is a very responsible chain strategy to pursue, to help them do so. Partly through social influence, social modeling on an implementation support system, but also because they’re best situated to make the change. In quality improvement terms they’re the people most likely to make productive adaptations to a given practice or program.

[Ed Maibach] The notion of fidelity of implementation is really apathetical to encouraging individuals and organizations to take your evidence-based work and apply it, so the principle here is just go with it, encourage it, enable it. And one way to do that is actually to make explicit the theory of change. Help people understand why this thing works. It’s not good enough to tell them in a document that it in fact does work and it has worked successfully elsewhere, but help them understand why it works because, in doing so, you enable people who don’t necessarily share your technical and theoretical training to sort of get it. To say, okay, I see and moreover I see therefore how it can and will work here if I’m willing to give it a whirl. Part of that is also helping people differentiate the core elements of the program, the active ingredients if you will, from the peripheral elements of the program. The stuff that you develop to make it fun or acceptable or just to sort of make it hang together as a whole program in a generic sense, but maybe none of that stuff is relevant or helpful in the unique settings in which it is being adapted for. So, unpack the theory of change. Help people identify the core versus the peripheral elements, which will, of course, help me, if I am the adopter in an organization, explain to my near peers why this is a good thing for us and what we need to do to adapt it to make it succeed here.

One of the really important core assets that we bring to this whole process is marketing research. Obviously, if we’re trying to take a product or a service that has been shown to be successful in a variety of implementation settings and encourage its wider scale implementation and adoption, the more we understand about both our customers, namely the organizations to whom we are trying to market, as well as their customers - the end-users that this very program is intended to benefit, the more adept we will be at selling the benefits that are of greatest interest to our customers and their customers and essentially engineering around the costs of the program that are of greatest concern. So, this whole notion of marketing research that we use to build the program in the first place has equal, if not greater relevance in our process of selling this through our supply channel to eventually reach the very people who we are hoping to benefit. One final point I want to make about marketing research is that I’m personally a huge convert of the notion of total quality improvement. And moving away from thinking about evaluation as something you do in the future and towards thinking about evaluation as something you do today so you can do your job better tomorrow and the next day and the next day. This is what makes Wal-Mart the biggest, baddest corporation on the face of the planet and I truly believe this is the kind of use that we can put marketing research to, to improve the output and the impact of our own work. And then the final principle that we want you to consider is that if you’re going to go to all of the effort to build a really high performing distribution channel for an evidence-based program, well, we would be very wise to actually put a bunch of evidence-based programming into the same distribution channel. Because by virtue of giving our customers choice, the choice of different evidence-based programs, any one of which is likely to improve the output of their work, we are actually doing a whole lot to reduce their innate reactance to our marketing offers in the first place. Consumers like choice. We don’t want to give them too much choice. Fortunately in public health we don’t have the R & D dollars to give them too much choice, but we do in most areas of public health activity we do have more than one evidence-based program. It’s definitely true with regard to physical activity programs. It’s definitely true with regard to HIV prevention programming and let’s go ahead and build - introduce - multiple products through the same distribution channels. Our customers will appreciate that we have done that.

[Jim Dearing] We see effectiveness in clustering like this in one of two ways, in both of two different ways. One is through what we call the establishment of complimentary clusters. This is just the creation of a set of evidence-based practices or offers that you’re making that are complimentary to each other. That is, the potential adopter could logically adopt more than one, maybe all of what’s portrayed on a website or what’s offered through a promotional vehicle or a set of alternatives within a cluster, an alternative cluster, which is simply adopting different one of a set of evidence-based practices. But, the adopter would only adopt one of those, right? They are in essence in competition with each other. Either can work well. The research on clustering attends to both of these ways of fitting evidence-based practices together. That is that with, especially with a complimentary cluster, once an adopter decides, once they make the decision to initially adopt, it lowers their degree of reactance, as Ed characterized it, to the others that are also portrayed. So if you can get over that initial hump, it makes the subsequent adoptions easier to achieve.

Ed Maibach] It was largely coincidental that we followed Jeff French’s presentation, which I thought was beautiful and really had a lot of interesting important lessons for us. I hope you saw some connections between our presentation and the ideas that he was suggesting. I certainly do. It’s certainly going to be cause for me to go back and think these ideas through at an even deeper level. So thank you very much.

Thank you.

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