SJPBS MS Id 000187

Scholarly Journal of Psychology
and Behavioral Sciences

DOI: 10.32474/SJPBS.2020.04.000187
ISSN: 2641-1768 Research Article
Applying Innovation Diffusion Theory to Determine

Motivating Attributes for Successful Implementation
of Internet-Based Interventions for Evidence Based
Medicine: a Developing Country Context
Fozia Anwar*
Faculty of Health Sciences, Higher Colleges of Technology, UEA
*Corresponding author: Fozia Anwar, Faculty of Health Sciences, Higher Colleges of Technology, UEA
Received: August 19, 2020 Published: September 07, 2020
Abstract
Current healthcare outcomes depend on the adoption of valid and latest research evidence and practicing evidence-based
medicine (EBM). EBM is the process of adaptation of the finest available scientific research evidence into routine clinical practice.
However, literature reports gap between actual and required clinical practice. This gap will not be bridged by just updating
physicians about EBM. Therefore, it is required to study the motivational factors in a context to use technology in routine clinical
practice as things behave differently under varying constraints. This study aimed to address this gap by investigating motivating
factors to promote EBM, focusing mainly on developing country context. Innovation diffusion theory will be used to provide the
basic or theoretical support for the research as this theory states that the adoption of any innovation is itself facilitated by its certain
characteristics. Cross-sectional quantitative methodology will be used for this research. SPSS and SEM will be used to analyze data
and validation of the tested research model. The innovation diffusion theory may provide constructive and practical insights into
the factors for the successful implementation of EBM, as well as it will provide a guideline for those who try to adopt the best-
evidences into their clinical practice.
Keywords: Innovation diffusion theory; Evidence based medicine; EBM; DOI Diffusion of innovation
Introduction
determining which components will need additional effort if
The innovation is a new idea that is observed by the individual.
diffusion is to ensure [4]. Literature showed applications of DOI
Evidence-based medicine is an innovation in the clinical decision-
in health departments as well [5-7]. Becker and Mohr worked to
making process, which promises to improve health care delivery
identify organizational characteristics linked with the diffusion
[1]. But at the same time, practicing EBM is a paradigm shift that
process among the health department [6]. One study found that
is changing the conventional way of the clinical decision-making
demographic features age, gender, education level, urban and rural
process [2]. Acceptance of any change or innovation in conventional
areas had a great impact on the time for adoption of innovation. It
clinical practices is always very hard, and multiple factors play
was noted that the initial adopters of innovations different by age,
their part in the adoption procedure [3]. The characteristics of
education and used information-seeking approaches as compared
innovation play a significant role in defining its rate of adoption [4].
to their jurisdictions who are varied by rurality [7,8]. Graduated
For an innovation to be adopted, it must be perceived as offering
younger people who had a higher standing in their graduating
relative advantage, i.e., simple, compatible, observable and testable.
class and belonged to urban areas were ready to adopt less risky
Roger proposes one of the theoretical approaches addressing
interventions. In comparison, older people in countryside areas
the diffusion of innovation (DOI). DOI model is supportive at
who had a normal standing in their graduating class, and they
describing the acceptance of explicit clinical events, mostly when
Copyright © All rights are reserved by Fozia Anwar. 433

Sch J Psychol & Behav Sci Volume 4 - Issue 3 Copyrights @ Fozia Anwar.
established their leadership roles were ready to take more risks, IDT is an important constituent of the upgrading health services
but they adopt less conventional innovations. It is also evident in worldwide, yet the literature illustrates that it is not always an
literature that large health departments easily adopt innovations easy theory to relate empirically [10]. IDT identifies five factors
than small health departments. The accessibility of funds and that influence the diffusion and adoption of an innovative idea or
human resources are the reasons which are supporting this finding strategy. The IDT offers a theoretical framework globally to accept
[8,9]. information technology. The role of ethnical background plays
an important part in the adoption of new ideas/technology as it
The effective implementation of EBM in the healthcare sector,
addresses that how, why, and what adoption rate of new technology
a better understanding of the motivating factors is required in
can relate with different social backgrounds and settings [11]. IDT
detail. Relation and association of factors with each other are also
not only addresses the adoption of information technology only, but
very important as the context is very special, and physicians have
it also addresses other diffusion processes through the society, such
autonomous authority in the clinical decision-making process.
as the acceptance of new technology products such as services,
Context and users of technology matter a lot because things behave
style of music, fashion, food, ideas, or political candidates [11-13].
differently under varying constraints. It is evident from literature
that the primary characteristics of the innovations have been This study builds upon what is known from past research on
conflicting as these are inherent in the innovation. These primary the diffusion and research conducted by Jenine K. Harris [8], which
characteristics are not dependent on the perceived characteristics described the significance to comprehend how health personnel
of the intended users. Augury of the potential user’s behavior perceives the relative advantage, simplicity, compatibility, and
depends on their perception about the primary traits as different testability of evidence-based decision making. Specifically, this
users may perceive the primary characteristics of the innovation research examined the effect of IDT factors, which can play a
in a different way, which can cause different behavior of the users. great motivational role for the physicians to adopt the new way
This is the origin of the problem of using the primary characteristics of the clinical decision-making process. Results are based on their
of innovation. perceptions and experience of practicing EBM. Rogers identified
five (05) elements of a new or substitute clinical behavior that can
Innovation Diffusion Theory (IDT) is used for this research
help in determining the adoption of a new activity such as EBM.
work because IDT is considered relevant and useful to researchers
These are relative advantage, compatibility, complexity, trialability,
conducting studies of information systems innovations in healthcare
and observability [14]. Definitions of all these four elements are
organizations. The IDT theory tries to explain the diffusion of new
given in Table 1 along with the hypothesized relations. All these
ideas, attitudes, opinions, and behaviors all over a community. The
variables are discussed below.
Table 1: Constructs with code and their hypothesized relation.
Constructs Code Definitions Hypothesized Relation

“The degree to which an innovation is perceived as better
Relative advantage RA RA UI
than using its precursors.” [4]
“The degree to which an innovation is perceived as being
Compatibility CM consistent with the existing values, past experiences, and CM UI
needs of potential adopters.” [4]
“The degree to which an innovation is perceived as
Complexity/ Simplicity SP SP UI
difficult to understand and use.” [4]
“The degree to which an innovation may be experimented
Trialability TR TR UI
with on a limited basis.” [4]
Observability to those people “The degree to which the results of an innovation are
OB OB UI
within the social system visible to others.” [4]
The subjective probability that he or she will engage in a
Usage Intention UI Dependent Variable
given behavior [14]
Independent variables perception of the advantages of innovation. Clinicians, patients, and

the healthcare system together decide the best-evidence practice
Relative advantage: The social prestige, satisfaction and
implementation. For instance, if a new clinical activity changes the
convenience, clinicians are some important factors for measuring
power distribution balance in professional groups in a negative way,
the degree of relative advantage. Relative advantage can also be
then the innovation cannot be successfully applied. On the other
measured in economic terms for a new clinical activity [3]. Objective
hand, if the proposed activity generates more revenue and benefits
advantage of innovation is less important as compared to clinician’s
Citation: Fozia Anwar. Applying Innovation Diffusion Theory to Determine Motivating Attributes for Successful Implementation of
Internet-Based Interventions for Evidence Based Medicine: a Developing Country Context. Sch J Psychol & Behav Sci. 4(3)-2020. SJPBS 434
MS.ID.000187. DOI: 10.32474/SJPBS.2020.04.000187.
the clinicians without disturbing the balance of power distribution, an intervention in medicine on a limited basis allows clinicians to
then innovation will be readily accepted and adopted. explore the implementation of the procedure, its acceptability, and
the possible outcomes. Rogers claims that the ability to undertake
Therefore, it is hypothesized that
limited cost-benefit experiments of an intervention endorses trust
H1: Relative advantage of EBM has a noteworthy positive effect and confidence that the evidence is not only, but its implementation
on the usage intention for EBM adoption. is logistically promising as well.
Compatibility: It is necessary for successful adoption of Therefore, it is hypothesized that

an innovation that it must tackle an issue that is perceived as
H4: Trialability of EBM has a significant positive effect on the
problematic by the clinicians. For instance, a new clinical activity or
usage intention for EBM adoption.
procedure will be adopted fast if it helps clinicians to detect cancer
or other life-threatening illness at very early stages [15]. It is a Observability: Observability means the idea of innovation is
strong medical belief that early detection of a disease is beneficial visible to others. The visibility of innovation’s results motivates
for the patients. Accordingly, clinical activity or procedure colleagues to discuss that particular innovation. Discussions on
offering this capacity will be adopted quickly. The rapid adoption the method or innovation by the influential physician will further
of mammography screening [16,17] and testing for prostate enhance the adoption rate. More clinicians will tend to adopt the
cancer are a few real-life examples. Though literature also has change in their clinical behavior if the role model practitioner is
some controversial debates about the therapy mentioned above more influential and charismatic. New techniques are often adopted
effectiveness. very quickly in the surgery department because of a common belief
that there are disadvantages in being “left behind” by not adopting
new technology.
H2: Compatibility of EBM has a significant positive effect on the
H5: Observability of EBM has a significant positive effect on the
Complexity/Simplicity: Literature proves that the probability
of adoption for a clinical procedure increases when the procedure
is simple, easy, and well defined. For example, the rate of change Dependent variable
in drug regimen for patients by clinicians is high and the reason
UI: In IS research, the system usage intention is a vital construct.
behind this phenomenon is that it is easy to adopt. While some
Self-reported usage is the only aspect of UI addressed by most of
precautionary activities as detecting and handling patients with
the researchers in quantitative studies. These studies adapted
harmful alcohol consumption [18] have not been adopted quickly,
self-reported usage to operationalize the actual system usage, in
though reported potential health gain in literature. This may be due
the absence of usage metrics. In technology acceptance studies
to the complexity of these activities. All preventions at the primary
intentions leads towards behavior [19]. The reason behind this is
level are vulnerable due to the patient’s resistance and their lack of
high values of correlation reported in the literature for the relation
accuracy in self-reporting risk behaviors. Additionally, inadequate
of intention and behavior. This research framework focused on
expertise in the consulting skills of clinicians necessary to achieve
the use of UI as a dependent variable because the use of UI as a
change may be the other reason.
dependent variable has literature support relative advantage
Therefore, it is hypothesized that and compatibility equivalent to PEOU and PU constructs. Under
conditions of incomplete volitional control, the intention cannot
H3: Complexity/simplicity of EBM has a significant positive
act as a sufficient predictor of the behavior [20]. Diagrammatic
effect usage intention for EBM adoption.
representation of the research framework along with dependent
Trialability: According to Rogers, “trialability” is the degree of and independent variables is given as Figure 1.
modification of an innovation. In other words, the capability to test
MS.ID.000187. DOI: 10.32474/SJPBS.2020.04.000187.
Figure 1: Research Model.
Methodology the next section (Figure 2). A total of 350 questionnaires were
distributed, and 290 responses were returned. Thus, the response
Sampling
rate was 82.85%. Total of twenty responses was discarded due to
A simple random sampling method was used to collect data. the same reply, missing responses or left blank and thus the usable
Random numbers were generated through the computer after response rate was 77.1% of the 270 respondents, 61.1% were
having access to the staff records of the physicians in the selected female doctors (Mean age= 38.3 years, SD= 10.7) and 38.9% were
hospitals. The self-administered questionnaire used as a data male doctors (Mean age= 40.1 years, SD= 9.83).
collection tool. A description of the questionnaire is provided in
Figure 2: Model Specialization.
MS.ID.000187. DOI: 10.32474/SJPBS.2020.04.000187.
Data collection tool evidence to suggest that these outliers were not part of the entire
population (Hair et al. 2006). Construct reliability for each construct
A structured close-ended questionnaire was used. At the
is calculated with alpha value and tabulated in Table 2 all values
beginning of the questionnaire definition of evidence-based
are within an acceptable range. After basic data screening process
medicine was provided to have a better understanding of the
factor analysis is performed.
concept. Demographic questions (were age, gender, organization,
and working experience) were included at the beginning of Factor analysis (FA)
the questionnaire. It was requested to the participants to give
FA is a multivariate regression analysis statistical method
feedback by thinking that practice evidence-based medicine will
used to analyze the correlation structure between different
be a requirement in the future for their routine clinical practice.
variables/constructs. In FA, after identifying latent dimensions of
The standard variable for innovation diffusion theory (technical
the constructs, data reduction was performed. Exploratory factor
compatibility, simplicity, relative advantage, and intentions) was
analysis (EFA) and confirmatory factor analysis (CFA) are two
used in the current research model. The variables derived from
steps in FA. The data is explored in EFA, while hypothesis is tested
other related studies on the extension of the IDT (Trialability and
in CFA [21]. For the current analysis, the researcher performed
Observability) were also included to have a deeper understanding
both steps of factor analysis. EFA: There are two main steps in EFA,
of the phenomenon. Seven (07) points Likert scale (1=strongly
which are extraction and rotation processes. The extraction process
disagree, 7=strongly agree) was used to code the responses. English
identifies the underlying factors or constructs, while the rotation
was the language of the questionnaire. All the constructs were
process yields an easy presentation of a factor loading pattern. In
measured through the validated items confirmed by the literature.
the current analysis, the researcher used the orthogonal rotation
Results and Discussion method for factor loading. Before performing factor analysis, we
Table 2: Reliability of the constructs. must check the suitability of current research data for sample
adequacy. For this purpose, we performed KMO and Bartlett’s Test.
Constructs Alpha Value
BI 0.946
Kaiser-Meyer Olkin (KMO) and Bartlett’s Test
CM 0.937 For the current research study, the value of the KMO test is 0.853,
OB 0.854 which shows the confidence about sample size adequacy to proceed
RA 0.945 for further steps of factor analysis. The result for Bartlett’s test can
SP 0.934 be interpreted on the value of significance. The value of significance
TR 0.909 is .000 confirmed that the analysis could continue by using factor
analysis as tabulated in Table 3. Furthermore, for exploratory
Data screening was performed to identify missing data. The
factor analysis (EFA), the principal components analysis (PCA) and
expectation-maximization technique was applied by using little’s
orthogonal model with varimax rotation method were applied. The
MCAR test, and it was found that the missing data was less than
result of principal component analysis also confirms the presence
10 percent, and it is missing completely at random. Missing data
of 6 factors explaining the total variance of the components as
were handled by using the mean substitution imputation method.
shown in Table 4. The results recommended the deletion of the
Skewness and kurtosis were checked to detect data normality at
item SP4 of Complexity/ Simplicity construct, as it was highly
a univariate level while Kolmogorov Smirnov and Shapiro Wilks
cross loaded on another latent factor, OB (observability). The
tests were performed to check multivariate normality. Results
graphical presentation of latent constructs based on eigenvalues
suggested that the data was normally distributed both at univariate
in EFA is shown in the scree plot (Figure 3). Scree plot plots all
and multivariate level. The linear regression method by using the
the eigenvalues in their decreasing order, where eigenvalues on
Mahalanobis distance test was performed to detect the presence
the vertical axis and factors on the horizontal axis. The scree plot
of outliers. Results revealed that the presence of the few outliers;
confirms the choice of 6 components.
it was, decided to retain all the cases, as there was insufficient
Table 3: KMO and Bartlett’s test of sphericity.
KMO and Bartlett’s test

Kaiser-Meyer-Olkin Measure of Sampling Adequacy. 0.853
Bartlett’s Test of Sphericity Approx. Chi-Square 6941.519
Df 406
Significance 0
MS.ID.000187. DOI: 10.32474/SJPBS.2020.04.000187.
Table 4: Total Variance explained.
Extraction Rotation
Initial Sums of Sums of
Component
Eigenvalues Squared Squared
Loadings Loadings
Percentage Cumulative Percentage Cumulative Percentage Cumulative
Total Total Total
of Variance Percentage of Variance Percentage of Variance Percentage
(%) (%) (%) (%) (%) (%)
1 14 48.259 48.259 13.995 48.259 48.259 4.733 16.319 16.319
2 2.25 7.759 56.018 2.25 7.759 56.018 4.618 15.924 32.243
3 2.03 7 63.018 2.03 7 63.018 4.07 14.036 46.279
4 1.82 6.263 69.281 1.816 6.263 69.281 3.961 13.659 59.938
5 1.48 5.094 74.374 1.477 5.094 74.374 3.781 13.038 72.976
6 1.4 4.811 79.185 1.395 4.811 79.185 1.801 6.209 79.185
7 0.54 1.873 81.058
Extraction
Method:
Principal
Component
Analysis.
Figure 3: Scree plot representing the eigenvalues.
Confirmatory factor analysis (CFA) the AVE, so the model satisfies the discriminant validity criterion. In
Table 7, the fit indexes for both measurement and structural model
CFA consists of the measurement and structural model. The
are given. Hypothesis testing is done by using the structural model.
measurement model used to evaluate the model validity and
It is noted that four out of five hypotheses are supported either
reliability. The reliability includes Cronbach’s alpha, while validity
at .001 (***) or .05 level of p-value; only one hypothesis BIOB is
includes discriminant validity. Whereas structural model is used to
rejected. Path diagram showing all the hypothesis is presented in
test the relationship between constructs. The result for discriminant
Figure 4. The most probable reason for the insignificant hypothesis
validity is shown in Table 5. The off-diagonal values represents
between observability and usage intention was that the software
correlation squared while diagonal values represent AVE In order
and information system had less observability by physicians, hence
to meet the criteria for discriminant validity, it is required that the
less rate of adoption as compare to hardware innovation [22].
AVE square root for each construct should be greater than the inter-
Consequently, the more potential user can see the innovation, the
construct correlation as tabulated in Table 6. It is also found that the
more likely he will adopt it.
inter-construct correlation value was not above the square-root of
MS.ID.000187. DOI: 10.32474/SJPBS.2020.04.000187.
Figure 4: Path Diagram.
Table 5: Discriminant Validity.
Correlations Squared OB RA SP CM TR BI
OB 0.865
RA 0.335 0.861
SP 0.41 0.566 0.86
CM 0.338 0.638 0.567 0.844
TR 0.291 0.573 0.585 0.6 0.818
BI 0.344 0.7 0.579 0.609 0.589 0.883
Table 6: Hypotheses testing.
Constructs Code Hypothesis Relationships P-value β Value Status

RA RA H1 BIßRA *** 0.401 Supported
CM CM H2 BIßCM * 0.146 Supported
SP SP H3 BIßSP * 0.135 Supported
TR TR H4 BIßTR ** 0.198 Supported
OB OB H5 BIßOB 0.042 Rejected
Table 7: Fit indexes for Measurement model and structure model.
Absolute fit Parsimonious fit Incremental

measure measure fit measure
CMIN Df CMIN/Df GFI RMSEA AGFI CFI NFI
Acceptable fit <3 >=0.90 <0.5 >=0.90 >=0.90 >=0.90
Obtained fit
437.573 356 1.229 0.899 0.029 0.876 0.988 0.939
MM
Obtained fit
456.46 357 1.279 0.896 0.032 0.873 0.985 0.937
SM
MS.ID.000187. DOI: 10.32474/SJPBS.2020.04.000187.
Limitation 2. Lambert H (2006) Accounting for EBM: notions of evidence in medicine.

Soc Sci Med 62(11):2633-2645.
This study has following limitations: 3. Sanson Fisher RW (2004) Diffusion of innovation theory for clinical
change. Med J Aust 180(S6):S55-S56.
a) Cross-sectional self-reported data limit this study.
4. Rogers EM (2010) Diffusion of innovations: Simon and Schuster.
b) Only one healthcare system, which might not reflect the
5. Becker MH (1970) Sociometric location and innovativeness:
factors for the successful diffusion of EBM in other health care Reformulation and extension of the diffusion model. American
settings. Sociological Review 35(2):267-282.
6. Mohr LB (1969) Determinants of innovation in organizations. American
c) Using an anonymous survey for data collection. political science review 63:111-126.
d) The small sample sizes. 7. Becker MH (1970) Factors affecting diffusion of innovations among
health professionals. American Am J Public Health Nations Health
Limitations of SEM include 60(2):294-304.
8. Harris JK, Erwin PC, Smith C, Brownson RC (2015) The diffusion of
a) The use of a model development process to improve evidence-based decision making among local health department
goodness of fit, which is sometimes referred to as a “post hoc” practitioners in the United States. J Public Health Manag Prac 21(2):134-
procedure for hypothesis formulation. 140.
9. Jardim JB (2008) Diffusion of innovations in health service organisations:
b) The use of goodness-of-fit measures to accept or reject a systematic literature review. Cadernos de Saúde Pública 24:1456-
a proposed model. These measures can inform the researcher 1457.
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superior model. Since in SEM the complete set is required for segmentation: the part played by people in promoting health. Sex
Transm Dis 33(7 Suppl): S23-S31.
analysis, therefore imputing missing data could affect the analysis.
11. Rogers EM (2003) Elements of diffusion. Diffusion of innovations 10:1-
Conclusion 38.
12. Rogers Everett M (1995) Diffusion of innovations, New York p.12.
Evidence-based medicine holds promise in improving health
13. Rogers EM (2004) A prospective and retrospective look at the diffusion
care quality and efficacy by improving the clinical decision-making
model. J Health Commun 9(Supply 1):13-19.
process. So far, health care is decades behind other industries
14. Fishbein M, Cappella JN (2006) The role of theory in developing effective
to adoption and use of information technology (IT). Though, health communications. Journal of communication 56(s1): S1-S17.
stakeholders in the health care sector have highlighted the urgent
15. McMullen H, Griffiths C, Leber W, Greenhalgh T (2015) Explaining high
need to adopt IT systems. This research work advocates that the and low performers in complex intervention trials: a new model based
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breast cancer mammography screening: A heuristic-based regression
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model. Omega 76: 70-84.
also unlikely to change absent significant incentives that have a
17. Mottet N, Bellmunt J, Bolla M, Briers E, Cumberbatch MG, et al. (2017)
positive impact on the new paradigm of clinical practice. Already EAU-ESTRO-SIOG guidelines on prostate cancer. Part 1: screening,
a lot of time elapsed between the introduction of sustainable diagnosis, and local treatment with curative intent. Eur Urol 71(4):618-
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MS.ID.000187. DOI: 10.32474/SJPBS.2020.04.000187.
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Scholarly Journal of Psychology

and Behavioral Sciences

ISSN: 2641-1768 Research Article

Applying Innovation Diffusion Theory to Determine

Received: August 19, 2020 Published: September 07, 2020

Copyright © All rights are reserved by Fozia Anwar. 433

Constructs Code Definitions Hypothesized Relation

Independent variables perception of the advantages of innovation. Clinicians, patients, and

Compatibility: It is necessary for successful adoption of Therefore, it is hypothesized that

Figure 1: Research Model.

Figure 2: Model Specialization.

KMO and Bartlett’s test

Table 4: Total Variance explained.

Figure 3: Scree plot representing the eigenvalues.

Figure 4: Path Diagram.

Table 5: Discriminant Validity.

Table 6: Hypotheses testing.

Constructs Code Hypothesis Relationships P-value β Value Status

Table 7: Fit indexes for Measurement model and structure model.

Absolute fit Parsimonious fit Incremental

Limitation 2. Lambert H (2006) Accounting for EBM: notions of evidence in medicine.

This work is licensed under Creative

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