Using Everett Rogers' Diffusion of Innovations Theory an intervention for automatic STI screening for adolescents is applied to primary care settings in Baltimore, Maryland.

1. Everett Rogers’ Diffusion of
Innovations Theory: Application for
Automatic STI Screening for Adolescents
By: Adrienne Bourguet, Zachary Furman, Caitlin Kelly, & Chelsea
Woodell

2. Overview and Objectives
This module will apply Everett Rogers' Diffusion of Innovations Theory to the implementation of automatic STI
screening for adolescent patients (13 years and older) in an urban primary care setting.
Learner Objectives:
After reviewing this module, the learner will be able to:
1. Describe the scope and significance of the problem related to adolescent STI in the United States.
2. Have a concrete understanding of Everett Rogers' Diffusion of Innovations Theory.
3. Will understand the rationale behind the application of his theory to the clinical problem.
4. Understand strengths and weaknesses related to the applicability of Rogers' Diffusion of Innovations Theory.
5. Apply Rogers' Diffusion of Innovations Theory to a clinical setting.

3. Required Readings and Supplemental Material
● Peterson, S.J., & Bredow, T.S. (2017). Middle Range Theories: Application to
Nursing Research and Practice (4th ed.). Philadelphia, PA: Wolters Kluwer Health.
○ Page: 288-290
● https://www.youtube.com/watch?v=P_Sh_MY0A44

4. Population
● This module defines the population as adolescents ages 13 years and older.
● The term adolescence is a newer term historically, as anthropologist Margaret
Mead was the first to question the experiences during adolescence in the 1950’s.
● Adolescence is a period of transition, as they endure physiological, emotional,
and behavioral changes.
● The majority of morbidity and mortality during adolescence is due to the
behavioral patterns acquired during this time period and include suicide, drug
use, and sexual ill health.
(Dehne & Riedner, 2005)

5. Practice Setting: Baltimore City Primary Care
● According to the Maryland Department of Health, the incidence of Gonorrhea, Chlamydia, and
Syphilis per 100,000 persons within Baltimore City has been consistently and dramatically
higher than cases within the entire state of Maryland and within the United States for the past
decade (Pena, 2017).
● Due to the significant burden of disease within this inner city population, the implementation of
automatic STI screening as an innovation within this setting may allow for a dramatic increase
in identification and treatment of STIs, and hopefully contribute to a significant decrease in STI
incidence and the significant morbidity and health care cost they incur on the adolescents and
young adults in Baltimore City.

6. Clinical Problem: What are sexually transmitted
infections?
● Sexually transmitted infections are a major public health problem in the United States, especially among
adolescents and young adults.
● Sexually transmitted infections are passed from one person to another person primarily through sexual
contact, including vaginal, anal, and oral sex . However, some sexually transmitted infections can be spread
by non-sexual means via blood or blood products or skin-to-skin contact.
● More than thirty different bacteria, viruses, and parasites are known to be transmitted by sexual contact.
Eight of the thirty pathogens are known to cause the greatest incidence of sexually transmitted infections:
Chlamydia, Gonorrhea, Herpes Simplex Virus, Human Papillomavirus, Syphilis, Trichomoniasis, Hepatitis B
Virus and Human Immunodeficiency Virus.
● Only four of the eight are curable, while the other four infections do not have a cure.
(WHO, 2017)

7. Incidence of Sexually Transmitted Infections
● The World Health Organization has estimated that there are over 300 million curable sexually
transmitted infections every year worldwide and 1 million infections are acquired everyday
worldwide.
● According to the Centers for Disease Control and Prevention (CDC), adolescents and young
adults aged 15-24 years old acquire half of the 20 million new sexually transmitted infections
(STIs) that occur in the United States each year.
● 1 in 4 adolescent females has an STI.
(CDC, 2016)

8. Barriers to Sexual Health Education and Prevention
● Due a combination of behavioral, biological, and cultural reasons, adolescents encounter many barriers
to accessing STI prevention and management services (CDC, 2016).
● Perceived barriers to adequate care include lack of knowledge, cost, transportation, confidentiality
concerns, embarrassment, and lack of available services (Tilson et al., 2004).
● Moreover, many adolescents and young adults also do not view the seriousness of STIs (Dehne &
Riedner, 2004).
● Adolescents are also unaware of their rights to confidentiality and minor consent.
● Lastly, it is crucial to consider that adolescents frequently underreport their sexual history, especially
relating to their use of barrier protection, for fear of judgement (Neal & Hosegood, 2015).

9. Magnitude of STIs: Adolescent Risky Behavior
● According to the Youth Risk Behavior Survey (2015), many adolescents are engaging in risky
health behaviors, including sexual risk behaviors.
● For instance, 41.2% of students reported having sex with at least 1 person in their life.
● Only 56.9% had used a condom during their last sexual intercourse and 13.8% reported no form
of contraception during their last encounter (Kann et al., 2016).
● Lack or inconsistent use of contraception is due to lack of education and misconception about
contraception and adolescents’ beliefs that they are immune to the problems and consequences
of sexual intercourse (AAP, 2014).

10. Magnitude of STIs: The “Silent” Infections
● Contributing to the spread of STIs is that most infections in both boys and girls go without
causing symptoms, until major health consequences occur (Dehne & Riedner, 2005).
● For instance, 85% of women with a Chlamydial infection did not have any symptoms
(Tilson et al., 2004).
● Even if adolescents do have symptoms, they are nonspecific symptoms, such as vaginal
discharge, vulvar itching, abdominal pain and urethral discharge (Dehne & Riedner,
2005).
● Because of this, many adolescents and young adults do not seek treatment, and thus, do
not receive the treatment they need, therefore perpetuating this public health problem.

11. Consequences of STIs: Negative Health Impact
● STIs can have serious consequences beyond the infection itself (WHO, 2017).
● STIs can cause a variety of life-threatening consequences, include infertility, ectopic pregnancy,
premature births, pelvic inflammatory disease, and anogenital cancer (Tilson et al., 2004).
● For instance, HPV causes 528,000 cases of cervical cancer annually and 266,000 cervical cancer
deaths each year (WHO, 2017).
● STIs can also be spread from mother to child, which can result in stillbirth, neonatal
conjunctivitis, sepsis, pneumonia, congenital deformities, low birth weight, and prematurity
(WHO, 2017).

12. Consequences of STIs: Financial Burden
● The annual cost of STIs was $10 billion in 2004, excluding HIV infections
(Tilson et al., 2004).
● Since 2004, the net incidence of Chlamydia, Gonorrhea, and genital warts
from HPV infections have all increased.
● In 2008, the lifetime direct medical cost for persons infected with HSV
type 2 in the U.S. was $540 million, significantly higher than the cost of
Gonorrhea, Syphilis, and Trichomoniasis combined (Kinney & Johnston,
2017).
● Pelvic inflammatory disease, most commonly caused by Gonorrhea and
Chlamydia, costs approximately $3,200 per individual diagnosed (Hahn &
Johnston, 2017).
● The annual cost of individuals with Syphilis infections is $39.2 million
dollars (Hahn & Barbee, 2017).

13. Nursing Significance: The Role of the PCP
● Pediatric healthcare providers have a vital role in promoting and providing adolescent
reproductive health care.
● Adolescents are also more reluctant to disclose sensitive information to their parents, yet
adolescents consider pediatricians highly trusted sources of sexual health information.
● It is also important for primary care providers to educate the adolescent on minor consent and
confidentiality.
● This education is especially important as limitations on confidentiality are linked to lower use of
contraceptives, resulting in higher rates of STIs, and pregnancy.
(AAP, 2014)

14. Nursing Significance: Current STI Screening
● The CDC recommends annual screening only for sexually active females for certain
STIs.
● Annually, all sexually active women under the age 25 will be screened with a cervical
swab only for chlamydia and gonorrhea, unless they complain of symptoms or are
receiving care in a high-risk practice setting.
● There is no routine STI screening for men.
(CDC, 2016)

15. Nursing Significance: STI Collection Methods
● Many adolescents avoid STI screening due to the unpleasant collection methods of
urethral swabs, cervical swabs, or blood samples.
● For instance, Tilson et al., (2004) interviewed 53 adolescents and young adults and
discovered that a urethral swab “is the worst solution” and that it would be more
tempting if it was “just a pee in a cup thing” (p. 4-5).
● STI screening tests are also difficult to perform and expensive, making it unlikely to
be affordable in lower income areas.

16. Nursing Significance: Lack of Successful
Interventions
● There have only been STI interventions targeting adolescents at an individual level.
● Many efforts have focused on prevention and education for those who are not
sexually active.
● There have not been successful interventions targeting adolescents who have already
engaged in sexual activity.
● If creative solutions are not used to solve this problem, this public health
emergency will continue to worsen.
(Dehne & Riedner, 2005)

17. Diffusion of Innovations Theory
● Please watch the following 3 minute youtube video for a succinct introduction to
the Diffusion of innovations theory:
● https://www.youtube.com/watch?v=P_Sh_MY0A44
● First developed in 1962 by Everett Rogers, with his fifth edition released in 2003.
● The theory emphasizes the adoption process of new knowledge and technology.
● His theory explains how and why new ideas spread and are adopted or rejected.
● He first applied his theory to agriculture technology. Today, his theory has been
applied to several disciplines, including medicine, education, and management.

18. Diffusion of Innovations Theory Concepts
● Diffusion is the communication of an innovation through certain channels over time
among the members of a social system
● Innovation is an idea, practice, or object perceived as new by an individual or other
unit of adoption.
● A technology is a design for instrumental action that reduces the uncertainty in the
cause-effect relationships involved in achieving a desired outcome.
● A communication channel is the means by which messages get from one individual
to another.
● A social system is a set of interrelated units that are engaged in joint problem solving
to accomplish a common goal. (Rogers, 1983)

19. Everett Rogers’ Diffusion of Innovations Theory
Five Steps to Creating an Innovation
1. Awareness
2. Interest
3. Evaluation
4. Trial
5. Adoption
(Peterson & Bredow, 2017)
Five Attributes that Influence Adoption:
1. Relative Advantage
2. Compatibility
3. Complexity
4. Trialability
5. Observability

20. Types of Adopters of Innovation

22. Rationale for Rogers’ Theory
● Rogers’ theory contains an easy to understand framework for intervention
development and dissemination.
● Rogers’ theory has clearly defined characteristics that influence innovation
adoption.
● Through understanding the characteristics that most influence innovation
adoption, successful design and implementation of an innovation is more
likely to occur.

23. Evaluation of
Roger’s Diffusion of
Innovations Theory

24. Significance
● Rogers’ theory does not explicitly address the nursing metaparadigm concepts, however much like health
care, the successful implementation of a new innovation is largely dependent on self sustaining capital of the
innovation which is possible because the innovation may save time, money, or is more efficient than what is
currently used, and therefore this theory is significant for nursing, healthcare, and public health.
● Rogers’ theory (2004) aims to describe the complex process of diffusion and acceptance of an innovation,
possibly a new technology, practice, or knowledge, into a social system and what is required for that
innovation to become adopted as the primary tool for practice.
● Rogers (2004) analyzed the Diffusion Model retrospectively, and discussed the Ryan and Gross study on
hybrid corn seed (1943) as providing the basic framework and paradigm for the diffusion model and laid the
groundwork for future diffusion research.
● The model first came about in a Sociology and agriculture setting, and has disseminated to marketing, news,
education, public health, nursing, pharmacy, management and more.

25. Consistency
● Rogers' theory is internally consistent, as his philosophical claims, conceptual model, and his theory
contain comprehensible and straightforward definitions and relational statements.
● Rogers (1983) defines the term diffusion as the “process by which an innovation is communicated
through certain channels over time among the members of a social system” (p. 34). He also developed a
new concept of innovation, allowing a variety of disciplines, including health promotion, marketing, and
medicine, to apply his theory to multiple fields.
● Rogers succinctly discusses the four main elements of diffusion, as well as his five-step process of
diffusion.
● There are no redundant concepts, yet Rogers does use certain concepts as mutually exclusive.
● Rogers’ theory is unique from Lewin’s Theory of Change, as Rogers’ discusses both planned and
unplanned spread of new ideas.
● Although his theory is an Organizational Change Theory, Rogers’ model focuses little on the processes
of change. (Hagerman & Tiffany, 1994)

26. Clarity
● The generality of his theory allows it to be applicable to a variety of nursing settings.
However, his theory does not focus on nursing’s holistic approach, causing
ambiguity.
● Although Rogers’ model is relevant to many different disciplines, diffusion is
difficult to quantify, as there are many unknown variables that are involved in the
adoption of a new innovation.
● Rogers also uses several terms interchangeably, which can create confusion. For
example, he uses the concepts “diffusion and dissemination”, as well as “technology
and innovation” as synonyms.
● Rogers’ lengthy theory has many components and steps, which can make it difficult
to comprehend. (Hagerman & Tiffany, 1994)

27. Testability
● Rogers’ theory poses some concern for testability because it is difficult to quantify the many
internal and external variables that influence the individual and group adoption of innovation.
● Health care providers have been noted to be more likely to adopt less risky innovations, but
larger care settings are more likely to innovate.
● Measurement of this theory's propositions associated with diffusion, namely relative advantage,
compatibility, complexity, trialability, and observability, can be assessed by a number of
existing models and instruments.
● Though the actual process of diffusion can be mathematically modeled and measured, there is
inherent risk of inconsistent research applicability and results due to confounding variables and
potentially erroneous predictive factor identification.
(Chaudoir, Dugan, & Barr, 2013)

28. Adequacy
● Substantial empirical support for successful macro and micro-level application of this theory
exists across multiple, varied disciplines, including agriculture, anthropology, education,
healthcare, political science, and sociology.
● There has been a systematic review of this theory's assertions over a considerable timeframe and
the resulting data has generally been viewed as conforming to these assertions.
● As this theory and much of its evidence did not originate in the healthcare field, nor intend to be
applied to related health innovations, this may also present a limitation to its effective
application to this specific domain.
● Through scholarly inquiry, this theory and its assertions have been open to refinement and have
evolved to some extent over time, leading to greater overall maturity and adequacy as it has
successfully endured much theoretical critique. (Brownson, Colditz, & Proctor, 2012)

29. Feasibility
● Rogers’ theory can be successfully implemented within a clinical setting without all
clinical staff receiving specialty education.
● Rogers’ theory could be used to solve many clinical problems, such as updating and
refining clinical practices and policies based on evidence.
● His theory could be used to help identify effective strategies for training staff on new
equipment and for identifying or designing ways to maintain competent practice with
high risk, low volume pieces of equipment.
● Using Roger’s five elements of adoption, protocols and policies can be developed and
adopted throughout single practices and entire health care domains.

30. Solution to the STI Epidemic in Adolescents
First, innovators identify the need for change:
1) Awareness: Knowledge of HCPs about the underreporting of sexual activity in
adolescents, and the risk associated with undiagnosed and untreated STI.
2) Interest: An innovator or group of innovators become interested in gathering all
available information to solve the problem of undiagnosed STI due to underreporting of
sexual activity.
3) Evaluation: Development of a detailed plan to change the practice standard within
the office. The Innovation: automatic screening for STI for all adolescents ages 13+ by
urine and blood specimen.
4) Trial: Testing the innovation – collect data regarding the identification of STI in
patients taking note of their admitted sexual history for a 6 month period.
5) Adoption: Successful identification and treatment of STI in patients who previously
reported no sexual activity or consistent use of barrier contraceptive, therefore the
automatic screening is adopted and maintained within the practice.
To disseminate our findings
in hopes to allow diffusion of
our innovation, we must
communicate our results.
This may be done by means
of publication, news, social
media, word of mouth, etc.
(Goodroad, Webb, & Bredow, 2017)

31. Implementation of the STI screening solution:
Innovation Decision Process: Completed by the social system/population Other primary care clinics in Baltimore
● This series of steps are dependent on the social system, some aspects may be influenced by the
innovators/innovation, however many may not be influenced by outside forces.
1) Knowledge: HCP or other decision making party (Administrators, Managers, etc) become aware of the automatic
STI screening program, and gain understanding of its function and potential use.
○ Typically through high quality literature, for example: Publication of the study and results of the
implementation of the automatic STI screening program within the initial clinic.
2) Persuasion: Decision makers and other practitioners form opinions about the innovation and consider its
consequences within their practice. See aspects on next slide.
(Goodroad, Webb, & Bredow, 2017)

32. Aspects of Persuasion
a. Innovation Aspects: Perceived advantage in comparison to current practice; compatibility with existing values,
beliefs, and needs; trialability of the innovation (can it be adopted on a small scale); observable benefits with
measurable outcomes; complexity of the innovation.
● More likely to be adopted if: they have high rates of perceived advantage, compatibility, trialability, and
observability, and they have low levels of complexity.
a. Individual Aspects: Leadership’s opinions; innovativeness of the social system (innovators, early adopters, early
majority, late majority, laggards); level of influence one HCP or unit has on others.
a. Environment Aspects: Decision making autonomy; urban/rural nature; prestige; competition; peer pressure.
● More likely to adopt an innovation if: urban nature = more autonomy, believe in the prestige of providing innovative
care, and engage in a sense of competition with other systems.
a. Organization Aspects: Structural influences such as complexity and functional differentiation; workplace culture;
communication systems; leadership support; resources for innovation.
● More likely to adopt an innovation in a workplace with greater complexity and functional divisions, workplace
culture that values research evidence, has functional communication systems, and whose leaders value change.
(Goodroad, Webb, & Bredow, 2017)

33. Implementation of the STI screening solution: Cont.
3) Implementation: Innovation put to use within the social system .
● Automatic STI screening is implemented by one or multiple HCP within another practice.
● Strategies to promote implementation: Education on the implementation and use of the innovation should be
conducted by a peer with individuals in their own practice settings, reminders should be set in place to provide
reinforcement, technology use as appropriate.
4) Confirmation: evidence of adoption is examined.
● Identification of STI in adolescents who report no sexual activity.
5) Reinforcement: visualization of success, benefits of the innovation must be relayed to those involved to reinforce
continued use.
● Provider or practice based statistics are presented to the administrators, managers, etc.
(Goodroad, Webb, & Bredow, 2017)

34. Potential Barriers to the Solution
● Failed diffusion of innovation may occur at the individual, group, or systems level, and each
level possesses its own unique and respective concerns.
● Individual: Individuals not only need to be internally aware and interested in change, but also
motivated and able to promote its implementation.
● Group: An affinity for uniformity in group thought and interpersonal interactions (homophily)
needs be present, but this must be balanced with a degree of diversity in the same respect
(heterophily) to allow adoption of new innovations.
● Systems: Specific external factors such as workplace culture, social networks, resource and
leadership availability, have to be conducive to diffusion or properly accounted for within the
system.

35. Application of Rogers’ Theory
● Using Rogers’ Diffusion of Innovations Theory, Smith, Dane, Archer, Devereaux, &
Katner (2000) developed a school-based sexual risk intervention to provide education
to adolescents on STIs and safe sexual health.
● Rogers’ theory has been successful in STI prevention programs, but has yet to be
applied to adoption of a universal screening for STIs for adolescents who are sexually
active.

36. Helpful Resources for Adolescents
● https://www.teenhelp.com/c/std-sti/
● http://www.ncsddc.org
● http://teenshealth.org/en/teens/sexual-health/?WT.ac=t-nav
● http://todayisfortomorrow.org
● https://www.adolescenthealth.org/Resources/Clinical-Care-
Resources/Sexual-Reproductive-Health/Resources/STIs-HIV.aspx

37. Test your Knowledge: Question #1: True or False
All STIs are transmitted through sexual contact.

38. Question #1 Answer
False
STIs can also be transmitted via skin-to-skin contact and blood products.

39. Question #2: Fill in the blank
_____ is the communication of an innovation through certain channels over time among
the members of a social system.

40. Question #2 Answer
Diffusion is the communication of an innovation through certain channels over time
among the members of a social system.

41. Question #3: Multiple Choice
What is the first step in Rogers’ Adoption of Innovation process?
a. Adoption
b. Awareness
c. Trial
d. Interest

42. Question #3 Answer
B. Awareness

43. Thank you!!

44. References
American Academy of Pediatrics (2014). Contraception for adolescents. Pediatrics, 4(1),
e1244-e1256.
Brownson, R.C., Colditz, G.A., & Proctor, E.K. (Eds.). (2012). Dissemination
and implementation research in health: Translating science to practice. Oxford,
NY: Oxford University Press.
Centers for Disease Control and Prevention (CDC) (2016). STDS in adolescents and young
adults. Retrieved from https://www.cdc.gov/std/stats15/adolescents.htm
Chaudoir, S.R., Dugan, A.G., & Barr, C.H. (2013). Measuring factors affecting implementation
of health innovations: A systematic review of structural, organizational, provider, patient,
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45. References
Dehne, K., & Riedner, G. (2005). Sexually transmitted infections among adolescents: The
need for adequate health services. Geneva: World Health Organization.
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46. References
Hagerman, Z.J., & Tiffany, C.R. (1994). Evaluation of two planned change theories. Nursing
Management, 25(4), 57-62.
Hahn, A.W., & Barbee, L.A. (2017). Gonorrhea. National STD curriculum. Retrieved from
https://www.std.uw.edu/go/pathogen-based/gonorrhea/core-concept/all
Hahn, A.W., & Barbee, L.A. (2017). Syphilis. National STD curriculum. Retrieved from
https://www.std.uw.edu/go/pathogen-based/syphilis/core-concept/all
Hahn, A.W., & Johnston, C. (2017). Pelvic inflammatory disease. National STD Curriculum.
Retrieved from https://www.std.uw.edu/go/syndrome-based/pelvic-inflammatory-
disease/core-concept/all

47. References
Harris, J.K., Erwin, P.C., Smith, C., & Brownson, S.C. (2015). The diffusion of evidence-based
decision making among local health department practitioners in the United States.
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Kann, L., McManus, T., Harris, W.A., Shanklin, S.L., Flint, K.H., Hawkins, J.A. … Zaza, S.
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https://phpa.health.maryland.gov/OIDPCS/CSTIP/Pages/STI-Data-Statistics.aspx

48. References
Rogers, E.M. (1983). Diffusion of Innovations (3rd ed.). New York, NY: The Free Press.
Rogers, E.M. (2004). A Prospective and retrospective look at the diffusion model. Journal of
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49. References
Tilson, E.C., Sanchez, V., Ford, C.L., Smurzynski, M., Leone, P.A., Fox, K.K., Irwin, K., &
Miller, M.C. (2004). Barriers to Asymptomatic Screening and Other STD Services for
Adolescents and Young Adults. Focus Group Discussions. BMC Public Health, 4(21), 1-
8.
World Health Organization (2017). Sexually transmitted infections (STIs). Retrieved from
http://www.who.int/mediacentre/factsheets/fs110/en/