In general, systematic research on dissemination of public health promotion programs is in its infancy. As noted above, theories and models need to guide such research; however, relatively few comprehensive models exist. Research questions abound, in terms of understanding the process and outcomes of dissemination. If we think about dissemination research as understanding the way that new innovations spread into society (both public health and clinical practice) then numerous unanswered questions can be posed. One way of defining relevant research questions is to examine gaps in research using four categories taken from Rogers' theoretical model, including (1) characteristics of: the innovation, (2) properties of the communication channel, (3) activities over time, and (4) the environment/system in which the dissemination is to occur. We have selected 3 dissemination research foci to use as examples, presented in .
Applying diffusion theory to cancer prevention and control
First, understanding the characteristics of the innovation is a key first step toward promoting its dissemination. Marketers have tremendous expertise in identifying unmet needs in their audiences and finding effective ways to create awareness and adoption by branding and promoting new products, but we know less about how to accomplish this in the public health arena. It cannot be overemphasized that careful formative research is critical in order to determine the needs/preferences of each target audience. For example, studies could examine views about the acceptability of new technological advances in different populations. Consuming fruits and vegetables is a common occurance in most people's diet, although not at the level needed to promote health. Awareness of HPV risk and potential vaccination for risk reduction, however, is likely to be low in situations where awareness of other sexually transmitted diseases is low and/or not an accepted topic of discussion.
Little research has rigorously examined specific intervention characteristics (e.g. trialability, flexibility, relative advantage, etc) to determine which ones are most operational in different types of organizations and/or with different types of interventions. For example, flexibility may be very important in disseminating programs aimed at organizations with a high degree of autonomy or with a lot of decentralized authority, such as churches. However, flexibility might be less important or even counter-productive in highly centralized organizations where fidelity to protocols or regulations is very important, for example in the dissemination of an evidence-based clinical practice in a hospital system.
Selecting the appropriate communication channel to transmit the package for dissemination is an important issue. For example, influencing provider recommendation behaviors has been shown to be difficult REF, partly due to the lack of an acceptable channel for disseminating new ideas. Delivering knowledge and support for using evidence-based screening promotion programs to providers, for example, could occur through continuing medical education sessions, through use of a web-based portal for provider education and support, or through advice from a trusted colleague, as in academic detailing. Or, as in many programs, a combination of these channels could be tested. The same channels would likely not work to disseminate and promote the use of a new vaccine for HPV risk reduction. For this research question the providers themselves could become the channel of dissemination, with appropriate support to patients.
Time is the third key factor in Rogers' model, containing many elements. Some research questions relevant to time might focus on studying how quickly systems and environments promote use of a new program or benefit, (e.g. relative impact of top-down directives, participatory strategies, interpersonal communication via viral marketing or lay health advisors), or the relative impact of these factors in a given subpopulations populations of workplaces or health care settings. Early adopters, those who use innovations early in the dissemination process, are likely to be different from those who are later adopters of the innovation. Therefore, motivations tailored to the adopter characteristics at different stages over time might be tested. For example, early parental adopters of the HPV vaccine might have strong beliefs that the health care system is trustworthy, while late adopters might express mistrust in the health care system as solution for preventing disease. In addition, how much support over time (e.g. technical, peer, supervisory, etc.) is needed to achieve adequate implementation once interventions move from researcher control to community control over program implementation and fidelity is a key issue. What system factors promote or hinder implementation (e.g. program novelty, personal commitment to the program/outcomes, personnel resistance/overwork, competing priorities, lack of belief in benefits) and how does this vary across systems? For example, difficulties in using evidence based programs in clinical settings might be due to lack of experience with electronic medical records, which might be an innovation themselves and might come to publically funded community clinics late in the process. Additional research questions might focus on later stages, such as factors necessary to establish program maintenance and indeed, what defines maintenance.
In addition, much research is needed to understand the characteristics of groups that exert their influence at different points in the dissemination process. We know, for example, that the role of program champions and opinion leaders can be critical in disseminating evidence-based programs and information in both clinical and community contexts. However, less is known regarding the specific contexts and settings in which opinion leaders may be most effective. In addition, who are these champions/pioneers and how do we best identify and train them? In a recent study, Grimshaw and colleagues surveyed professional groups in the UK National Health Service to determine factors impacting effectiveness of opinion leaders, such as extent of social networks and types of identification processes (65
). In another example, Valente and Pumpuang (66
) recently reviewed over 200 studies utilizing different techniques and methods of identifying opinion leaders, in order to study factors such as relative effectiveness and convergence of these methods in identifying individuals to serve in this capacity. In addition to identification of these groups, we need to know the impact of utilizing such champions/leaders in terms of their personal and professional growth, reputation and status, role conflict and burden, or other positive or negative consequences.
Finally, characteristics of the social system that is the intended target of the dissemination process need research attention. For example, disseminating a mass media program kon fruit and vegetable consumption to a large geographic area may not be the most efficient method of reaching the target audience to to lack of exposure to the media outlet, such as a billboard on the highway. Differences among clinics' resources and support will, in part, determine the amount of evidence based programs that can be incorporated into standard practice.
It is important to differentiate between research questions that truly focus on dissemination research, versus other types of research questions that are important and relevant, but don't speak specifically to dissemination. For example, a study that seeks to determine whether an intervention with proven efficacy in one population can be translated to another population or setting may be better characterized as a replication study, and not a dissemination study. As the field matures and agrees upon needed research strategies, we will likely be able to make these distinctions more easily.