Content uploaded by Robin Lin Miller
Author content
All content in this area was uploaded by Robin Lin Miller on Feb 18, 2014
Content may be subject to copyright.
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
American Journal of Community Psychology, Vol. 29, No. 4, 2001
Innovation in HIV Prevention: Organizational
and Intervention Characteristics Affecting
Program Adoption1
Robin Lin Miller2
University of Illinois at Chicago
A multiple case study design was used to explore the organizational charac-
teristics of community-based organizations that provide HIV prevention pro-
grams and the criteria these organizations employ when judging the merits
of externally-developed HIV prevention programs. In-depth interviews were
conducted with organizational representatives of 38 randomly-selected HIV
prevention providers throughout Illinois. Results indicated that there were
three main types of adopting organizations: adopters of entire programs,
adopters of program components and practices, and adopters of common
ideas. These three types of organizations were distinguished by their level of
organizational commitment to HIV prevention, organizational resources, and
level of organizational maturity. Narrative data from the interviews are used
to describe the dimensions that underlie the organizations’ program adoption
criteria. The criteria of merit used by these organizations to evaluate prevention
programs provide partial empirical support for existing theories of technol-
ogy transfer. Implications for designing and disseminating HIV prevention
programs are discussed.
KEY WORDS: HIV prevention; technology transfer; community-based organizations.
1This study was partially funded by a grant from the Campus Research Board of the University
of Illinois at Chicago. I gratefully acknowledge the assistance of Heather Barton, Barbara Joyce
Bedney, Dalia Garcia, Caroline Leopold, Dana Merrit, and Corina Rico in the collection and
analysis of these data, and Rebecca M. Campbell, James G. Kelly, Christopher B. Keys, Miles
A. McNall, Bianca Wilson, and two anonymous reviewers for their feedback on earlier drafts
of this paper.
2To whom correspondence should be addressed at Department of Psychology (M/C 285),
University of Illinois at Chicago, 1007 W. Harrison St., Chicago, Illinois 60607-7137; e-mail:
rlmiller@uic.edu.
621
0091-0562/01/0800-0621$19.50/0 C
°2001 Plenum Publishing Corporation
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
622 Miller
INTRODUCTION
The prevention of HIV infection represents an urgent concern world-
wide. HIV has claimed substantial portions of the adult population in many
developing and developed nations. At present, the estimated HIV seropreva-
lence rate worldwide is 30 million and in the United States current estimates
suggest that nearly 1 million people are HIV infected (UNAIDS/World
Health Organization, 1997). Unlike many other chronic diseases, HIV re-
sults in mortality in the most productive years of adult life. Most HIV-related
mortality in the United States occurs among men and women aged 25–44
(Centers for Disease Control and Prevention, 1997). In one recent estimate,
New York City’s gay community had lost one-half million person years of
life by 1993 to AIDS (Fordyce et al., 1995). With the likelihood of a cure or
vaccine far in the future, prevention remains our best approach to stemming
the tide of the epidemic.
Behavioral Science, Community Organizations, and the Prevention of HIV
Government and private agencies have invested substantial resources
in basic behavioral research and experimentally-developed interventions
to reduce HIV-related risk-taking behavior. Recent reviews of published
HIV prevention interventions (Choi & Coates, 1994; Kalichman, Carey, &
Johnson, 1996; National Institutes of Health, 1997; Office of Technology
Assessment, 1995; Trickett, 1998) suggest that these programs have had de-
sirable short- and long-term effects on risk-taking behavior for a variety of
at-risk populations. Theoretically-based and delivered by well-trained staffs,
these prevention programs represent the “gold-standard” of HIV preven-
tion from the perspective of prevention science. However, there is little evi-
dence that the majority of these successful interventions have been adopted
for ongoing implementation (DiFranciesco et al., 1999; Goldstein, Wrubel,
Faigeles, & DeCarlo, 1998; Haynes-Sanstad, Stall, Goldstein, Everett, &
Brousseau, 1999; Office of Technology Assessment, 1995). As has been the
case in many other mental health and health arenas, there is an apparent
gap between science and practice in the field of HIV prevention.
In the United States, the majority of HIV prevention services are pro-
vided by community- based organizations (CBOs, Altman, 1994). Epidemio-
logic projections suggest that the prevention activities of these organizations
have substantially contributed to the decline of new HIV infections among
select populations in the United States (Becker & Joseph, 1988), popula-
tions that are often difficult for public health officials and university-based
scientists to access. Given their central role in providing HIV prevention
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
Innovation in HIV Prevention 623
services to communities, CBOs are a natural audience for the dissemination
of well-tested HIV prevention programs and a unique resource for preven-
tion scientists to learn about the intricacies of conducting preventive inter-
ventions in communities. Improved understanding of the programs provided
by CBOs is also crucial for bridging gaps between prevention science and
practice.
Although prevention scientists may concur on the importance of dis-
seminating empirically-validated programs, it is not clear whether CBOs
perceive that what prevention science might offer should replace or could en-
hance what they currently provide (Goldstein et al., 1998). Lack of rigorous
evaluation of CBOs’ programs in the published literature makes it unclear
whether CBOs should be dissatisfied with their programs and how motivated
these organizations might be to seek externally-developed technology (for
recent exceptions, see Freudenberg & Zimmerman, 1995; Haynes-Sanstad,
Stall, & Doll, 1999; Miller, 1995; Miller, Klotz, & Eckholdt, 1998). The wealth
of knowledge that has been accumulated by CBOs about prevention pro-
grams over the course of the epidemic remains largely part of each orga-
nization’s oral history and has been infrequently disseminated outside the
CBO community. There is also little documentation within the realm of
HIV about the needs and concerns of CBOs—the potential users of social
science prevention technology. Thus, there is a need to understand CBOs’
perceived need for and attitudes toward externally-developed HIV preven-
tion programs. This information is critical if the development, dissemination,
and transfer of empirically validated programs to community settings is to
occur.
Factors Affecting Technology Transfer
There is a burgeoning literature on factors that affect the science-
practitioner gap (e.g., Altman, 1995; Morrissey et al., 1997), technology trans-
fer processes (e.g., Backer, David, & Soucy, 1995; Baldridge & Burnham,
1975; Rogers, 1995; Mayer & Davidson, 2000), and the probability that in-
novations will be sustained in community settings (e.g., Shediac-Rizkallah
& Bone, 1998; Steckler & Goodman, 1989). Much of this literature points
to four critical sets of factors that affect the technology transfer process: (1)
characteristics of the innovations to be adopted and sustained, (2) charac-
teristics of the relationships and communication patterns among key actors
(e.g., inventor, adopter), (3) characteristics of the organizational entities into
which technologies are to be disseminated, and (4) characteristics of the set-
tings in which adopter institutions are located. In this paper, we consider
two of these domains: the characteristics of innovations and organizations.
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
624 Miller
Characteristics of Innovations
Diffusion of Innovations Theory (Rogers, 1995) has been widely used
to describe the factors that affect an individuals’ decision to adopt or reject
an innovation. For Rogers, an innovation is an idea, practice, or technolog-
ical advance that is perceived to be new by a potential adopter (Rogers,
1995). For the purpose of this paper, an innovation is defined as an HIV pre-
vention program that has been developed by sources external to the CBO.
These externally-developed innovations may include programs developed
by other CBOs, for-profit health education corporations, or university-based
prevention scientists.
Rogers’ work on the characteristics of innovations places its emphasis
on how an individual perceives an innovation, as individual perceptions of
the characteristics of innovations are likely to influence how an individual
makes choices about the various options that are available to him or her.
Rogers’ work is largely concerned with technological innovations, such as
computers, solar energy, and agricultural technologies, but has been widely
applied to other types of innovations, such as health promotion programs
(Mesters & Meertens, 1999; Orlandi, Landers, Weston, & Haley, 1990).
Rogers identifies five characteristics of an innovation that affect whether
an individual adopts it. Relative advantage refers to the degree to which
an innovation is perceived by its potential adopters to possess advantages
over a program that is currently being implemented (or is better than doing
nothing). In the case of an HIV prevention program, a program that is
perceived to represent little or no improvement over how things are currently
done by a CBO is unlikely to be adopted. Potential adopters’ judgements
regarding relative advantage may be based on any number of factors, such
as cost-effectiveness of the program or increased status conferred upon an
organization by its association with a particular program.
An intervention’s compatibility with an individual’s values, beliefs, expe-
riences, and needs is a second critical factor related to its potential adoption.
An HIV prevention program that is congruent with the culture, experience,
and needs of a prospective adopter organization would have a higher likeli-
hood of being adopted. Compatibility has also been identified as an essential
factor in a program’s long-term adoption and institutionalization (Shediac-
Rizkallah & Bone, 1998; Steckler & Goodman, 1989).
A third factor affecting adoption concerns an innovation’s level of com-
plexity. Adoption of an HIV prevention program that is perceived as diffi-
cult to understand and use is less likely than one that is perceived as easy to
understand and use. Complexity could be a function of many program fea-
tures such as its technical requirements (e.g., requires clinically-trained fa-
cilitators), conceptual sophistication (e.g., employs advanced psychological
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
Innovation in HIV Prevention 625
concepts and language) or the number of program sessions needed in order
to create behavior change.
Trialability refers to the degree to which an innovation, in this case an
HIV prevention program, can be implemented on a limited, trial basis. Inno-
vations that can be gradually implemented or implemented on a small-scale,
trial basis before one has to commit to full-scale program implementation
may be most readily adopted.
Finally, observability refers to whether the results or benefits of an inno-
vation (e.g., increased condom use) are easily observed and visible. Programs
that have visible benefits are more likely to be adopted than programs that
have benefits that are more difficult to detect.
Research on the adoption of social programs has not provided consistent
support for each of the factors outlined in Diffusion of Innovations Theory
(Mayer & Davidson, 2000; Mesters & Meertens, 1999). Research regarding
the diffusion of social program innovations is also largely in its infancy.
Therefore, it remains important to explore how characteristics of innovations
affect program adoption decisions and whether additional characteristics of
innovations influence adoption processes.
Characteristics of Organizations
Research has identified structural characteristics of organizations (e.g.,
formality, hierarchy, centralized decision-making, stability, maturity) that
appear to facilitate adoption of externally-developed programs, practices,
and innovations (Aiken & Hage, 1971; Baldridge & Burnham, 1975; Hage
& Aiken, 1970; Rogers, 1995; Steckler & Goodman, 1989; Thompson, 1967).
A limited body of research suggests that organizations that adopt externally-
developed programs have complex and well-defined subsystems, are large,
and are well financed (Baldridge & Burnham, 1975; Shediac-Rizkallah &
Bone, 1998; Steckler & Goodman, 1989). These organizations also tend to
be mature and stable (Shediac-Rizkallah & Bone, 1998; Steckler & Good-
man, 1989). In general, it is believed that adopting externally-developed
programs requires that an organization have the financial means to do so,
as well as the personnel and management infrastructure to implement the
program—characteristics of large, old, stable organizations. Organizations
must also have sufficient complexity to be able to scan the broader envi-
ronment for potential performance-enhancing programs, an ability that is
typically more common among large organizations with highly differenti-
ated internal functions.
The organizational characteristics of HIV-related CBOs appear to have
little in common with those of organizations that adopt externally-developed
programs and innovations. Unlike the organizations that have been most
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
626 Miller
often studied (e.g., school systems, health departments, corporations), the
prototypical HIV-related CBO grew out of a socially marginalized, HIV-
affected community that was perceived to have been neglected or served
poorly by traditional providers (Altman, 1994; Freudenberg & Zimmerman,
1995). These organizations’ missions are to provide community-based re-
sponses to the disease and its physical, emotional, and political sequelae. As
such, these organizations often combine a social service agenda with a social
change agenda. Furthermore, the people who work for CBOs often repre-
sent a collective social identity (e.g., gay men, prostitutes) or form one in
response to being similarly affected by HIV (Altman, 1994). Because CBOs
frequently represent marginalized groups in society, many are inherently po-
litical entities, seeking to empower their constituents and demanding change
in basic social arrangements, in addition to providing services.
HIV-related CBOs are also typically resource poor organizations. A
recent national survey of 142 full service AIDS and gay and lesbian organi-
zations found that the median number of full- and part-time paid staff was
between 11 and 25 people and that the median number of active volunteers
in these agencies was between 51 and 100. The median budget for these
organizations was between $500,000 and $1,000,000, with nearly half of the
organizations receiving 51% or more of these funds from government grants
(McCormack & Associates, 1997). Only 13% of the sampled organizations
owned their facilities. In another recent study of 77 AIDS service organi-
zations located in metropolitan areas with populations larger than 80,000,
DiFranciesco et al. (1999) found that respondents’ HIV prevention bud-
gets ranged from $4,500 to $1,080,000, with a median prevention budget of
$175,000. These organizations had a median number of 5 HIV prevention
staff members and 26 HIV prevention volunteers. Also of note in these data
was that the median tenure of prevention staff was 1 year and of prevention
directors was 2 years. These data suggest that AIDS-related CBOs may not
have the prerequisite organizational characteristics to adopt a wide range of
prevention programs.
The Present Study
The goal of the Illinois HIV Technology Transfer Project was to un-
derstand HIV-related CBOs’ perspective on the process of HIV prevention
program development and experience of adopting or rejecting externally-
developed HIV prevention programs. Specific areas of interest in the study
included identifying the primary challenges to program implementation
faced by CBOs, typical program resources and constraints, valued character-
istics of programs, and sources of influence on programs and the effect those
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
Innovation in HIV Prevention 627
sources have on prevention practice. These issues were examined qualita-
tively in a statewide, randomly selected sample of CBOs through open-ended
interviews. In the present paper, we discuss the organizational characteris-
tics of these CBOs and the factors that have affected these CBOs’ decisions
to adopt and reject externally-developed HIV prevention programs.
METHOD
Participants
Participant organizations were 38 not-for-profit HIV-related prevention
service providers located throughout the state of Illinois. Respondents were
randomly selected to participate in the study from an unduplicated list of
129 HIV-related prevention service providers throughout the state. The list
of potential respondents was generated from national and local directories
of AIDS-related service providers (HIV/AIDS Resources, 1995; Test Pos-
itive Aware Network, 1995) and lists of HIV-related prevention programs
funded by the state and city health departments. The list was independently
checked for errors and omissions by a staff member of the AIDS Founda-
tion of Chicago who was knowledgeable of HIV prevention service provision
statewide and by a member of the research team. Once a final list was ob-
tained, organizations were stratified by location (urban, suburban, rural)
prior to their random selection.
The goal of the study was to obtain rich, descriptive data, so we sought
to limit the size of the study sample to no more than 45 organizations—25
urban, 15 suburban, and 5 rural organizations. Random selection proceeded
iteratively within each strata. When an organization was randomly selected,
we assessed its eligibility and attempted to enroll it in the study before
proceeding to select another organization at random from that particular
strata. Organizations were eligible to participate if they had existed for at
least 1 fiscal year, had four or more staff, devoted a minimum 25% effort to
HIV prevention, and had not-for-profit (501(c) 3) status.
In all, we had to randomly select a total of 102 organizations in order
to achieve our desired sample size. Among the total of 102 organizations
selected at random to participate, 41 (40%) were enrolled in the study and
interviewed successfully. Among the remaining organizations, 38 (37%) did
not meet study eligibility criteria, most often because the organization de-
voted little of its effort to HIV prevention (n=31) or had fewer than four
staff (n=5). Seventeen organizations (17%) were unreachable. Of these, 11
organizations’ phones had been disconnected and we were unable to locate
a new telephone number or the organizations had closed; in the remaining
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
628 Miller
cases, we were unable to speak with the target representative after six or more
attempts. Five organizations (6%) refused to participate. Each of these five
organizations stated that they were too busy to participate and, in one case,
stated that they were also participating in other studies that already took
too much of their time. All of the organizations that declined to participate
had a primary mission as a substance abuse service provider. Two of the re-
fusals were from organizations located in suburban areas and the remainder
were from Chicago. During the course of data collection, two organizations
merged and were ultimately considered a single organization. Three orga-
nizations were ultimately excluded from the present analyses because of
problems associated with the tape recording and transcribing of their inter-
views, leaving a total sample of 38 organizations (urban =21, 55%; suburban
=13, 34%; rural =4, 11%).
Procedure
A letter from the research group was mailed to all 129 potential respon-
dents describing the study. A letter from the AIDS Foundation of Chicago
endorsing the study was also separately mailed to all potential respondents.
When each organization was randomly selected, we called to confirm their
eligibility to participate and to enlist their participation. If an organization
was eligible and willing to participate in the study, we arranged an in-person
interview. A short questionnaire requesting information about the organi-
zation’s financial and personnel resources and a written informed consent
was sent in advance by mail or facsimile and collected at the interview. We
conducted in-person interviews for those CBOs within about a 4-hr round
trip drive from the Chicago area. CBOs that were located farther away were
interviewed by telephone. Interviews were conducted in either English or
Spanish. All interviews were tape-recorded and transcribed verbatim. Re-
spondents within the organizations were the executive director or the person
named by him or her as most knowledgeable about the organization’s HIV
prevention programs. Interviews lasted from 47 to 140 min in length (mean =
71 min). All interviews were conducted between May and November of 1997.
Measures
The open-ended interview protocol for this study was developed in
part based on Diffusion of Innovations Theory (Rogers, 1995) and Altman’s
historical analysis of the emergence, development, structure, and functions of
AIDS-related community organizations (Altman, 1994). The initial protocol
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
Innovation in HIV Prevention 629
was reviewed by several CBO representatives and experts from NIMH’s
technology transfer panel. The protocol was revised, pilot-tested with sev-
eral CBOs, and then revised again. The final protocol asked CBO represen-
tatives to provide an historical overview of their HIV prevention programs
and discuss program resources and constraints, program values, program
adoption and rejection experiences, important sources of influence on how
they design and implement prevention programs, and valued sources of in-
formation about prevention. We also asked about how HIV prevention fit
within the overall organizational context, organizational decision-making
processes, and intraorganizational relationships.
Prior to the interview, representatives completed a brief closed-ended
survey that was collected at the time of the interview. Representatives were
asked to list the sources and amounts of their organizational and preven-
tion funding; numbers of full-time and part-time, paid and unpaid HIV
prevention personnel; percentage of the paid prevention staff that were
members of the target population; and number of clients served by the
organization. We also collected annual reports and other promotional ma-
terials developed by the organizations to describe their prevention
programs.
Data Analyses
Given the exploratory nature of the present investigation and our desire
to discover the criteria that were used by CBOs to understand the merits
of prevention programs and whether those criteria overlapped with charac-
teristics described by Rogers, we took a grounded theoretical approach to
data analyses (Miles & Huberman, 1994; Strauss & Corbin, 1990). Grounded
theory is a progressively theory driven process in which the researcher em-
ploys an emergent, deductive, structured process to seek regularities in the
data. Five coders independently developed an initial set of coding domains by
each reading two transcripts verbatim. The initial coding domains developed
by coders concerned resources, values, program types, program implemen-
tation processes, valued characteristics of interventions, funding, program
barriers, relationships, information sources, and program adoption and re-
jection experiences. The initial codes also deliberately included topics that
reflected characteristics of innovations outlined in Diffusion of Innovations
Theory.
After each coder had developed an initial set of codes, the coding team
met to develop a common set of codes based on the initial code develop-
ment work. Once the team had agreed on a single coding scheme, coders
then independently applied the initial set of common codes to two more
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
630 Miller
interviews, revising and refining codes and creating additional codes that
emerged from the texts. The initial codes were also further refined to include
additional levels of subcodes. The team then met to review the common cod-
ing scheme and discuss additions, deletions, and revisions. Once a revised
scheme was developed, team members independently applied the revised
coding scheme to two more interviews. The research team repeated this
process six times before settling on a final coding scheme. Throughout the
coding process we sought to use our respondents’ labels for the criteria
that they described, so that our codes would reflect the meanings given
to them by our respondents. Initial check-coding (Miles & Huberman, 1994)
at this stage of the code development process produced interrater agree-
ments ranging from 75% to 92%.
Once a final coding scheme was established, each interview was coded
by two members of the research team, each working independently. Code sta-
bility was established by comparing agreement among independent coders.
When coders disagreed in their assignment of a particular code to the text,
the disagreement was discussed among the entire research team until a con-
sensus was reached among all coders regarding the appropriate code assign-
ment for the particular segment of text. Because a consensus-based dispute
resolution procedure was used, final interrater reliabilities are 100% for all
variables.
We created several variables from the text to assist us in describing the
organizations. Organizational structure was coded based on the organiza-
tional chart. We counted the number of levels between the executive direc-
tor and the first managerial position responsible for prevention programs
as a measure of the significance of prevention within the organizational
hierarchy (hierarchy). We also counted the number of managerial direct re-
ports to the executive director as an indicator of organizational complexity
(EDReports).
Organizational mission was coded based on the CBOs’ organizational
charts and on the respondents’ answers to questions regarding where HIV
prevention fit within the overall structure of the agency. Organizations that
provided non-HIV-related services (e.g., drug treatment, maternal–child
health services) or that expressly stated their organizations’ missions were
broader than HIV were coded as non-AIDS-service organizations (all others
were coded as AIDS-service organizations).
The target populations of the organizations were coded based on the
respondents’ descriptions of who the organization sought to serve. We cre-
ated separate variables to describe the primary target populations of the
organization and of their prevention programs, because organizations might
target multiple populations and because organizations might target differ-
ent groups at the level of the organization than at the level of a specific
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
Innovation in HIV Prevention 631
HIV prevention program. If the respondent stated that the organization or
its prevention programs served Asian Pacific Islanders, Blacks, Hispanics,
or Native Americans exclusively, it was coded as “ethnic minority.” Orga-
nization and program descriptions were coded “Yes” or “No” for targeting
services to gay, lesbian, bisexual, or transgendered individuals; substance
users; youth; men; women; incarcerated populations; homeless populations;
and, sex workers.
Respondents were asked to describe each of the HIV prevention pro-
grams offered by the agency. Programs were coded by type (social market-
ing, one-on-one outreach, small group workshops, social and performance
events, educational forums, other). We also counted the total number of dis-
tinct HIV prevention programs provided by each organization. Outreach or
marketing efforts that had the primary purpose of recruiting individuals into
other programs or advertising agency services were not coded as prevention
programs.
For the present analyses, organizations were divided into three groups:
those that reported that the organization had never adopted an HIV pre-
vention program or component of a program from an external source (n=
13; 34%), hereafter called low adopters; those that reported that they had
adopted a component of an HIV prevention program (e.g., a single behavior-
change module or exercise from a workshop) or a specific common behavior-
change practice, but not an entire program, from an external specified source
(n=13; 34%), hereafter called moderate adopters; and those that reported
that they had adopted one or more specific HIV prevention programs from
an external specified source in its entirety (n=12; 32%), hereafter called
high adopters. It is important to note that these groups form three distinct
adoption profiles; our labels should not be construed as suggesting that adop-
tion status is a unidimensional, linear construct.
For comparative analyses among adopter groups and nominal variables
such as having an exclusively AIDS-related organizational mission, we em-
ployed chi-square tests for k-independent samples (Pett, 1997). For those
analyses in which we compared adopter groups and ordinal variables, such as
location, Mantel-Haenszel chi-square tests for trends were applied (Mantel,
1963; Mantel & Haenszel, 1959). Finally, for those analyses in which we
compared adopter groups and ratio variables, such as organizational bud-
get, we employed the Kruskal–Wallis ANOVA by ranks test (Kruskal &
Wallis, 1952) or median tests for independent samples (Pett, 1997).3Mea-
sures of association (Cramer’s νfor chi square tests and Spearman’s ρfor
tests of ranks and medians) were also computed.
3Several variables, such as budget, had highly skewed distributions, making median tests more
appropriate.
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
632 Miller
RESULTS
Organizational Characteristics
Table I summarizes organizational characteristics and resources across
the entire sample and by adoption status. Univariate tests of significance
(chi-square, median, or ranks, as appropriate) and measures of association
(Cramer’s νand Spearman’s ρ) were computed to contrast organizations
by adoption status on these descriptive variables.
The CBOs in the sample were an average of 16.3 years old (median =
11 years; mode =11 years). However, the majority of CBOs in the sample
were young organizations; 65% of the CBOs were founded in 1985 or later
(n=24), with a peak during 1987 and 1988. About half of the providers in
the sample (n=18) were exclusively HIV-service organizations; about 95%
of these were founded after 1985. The remaining 53% of CBOs had broader
missions; all but one of these organizations were founded prior to 1988, with
a majority (63%) founded in 1980 or earlier. Nearly one third (n=11; 29%)
of the organizations served an exclusively ethnic or racial minority target
population. Most of these organizations (64%) were among those founded
in or after 1987.
The typical organization in the sample had a median budget of $478,593
(range =$4,000–$12,000,000) and served a median number of 3,000 clients
(range =120–200,000) in fiscal year 1996. Organizations spent an average of
37% of their organizational budget on HIV prevention programs
(SD =36); the median prevention budget was $56,121 (range =$0–$700,000).
The average organization in the sample offered 2.2 distinct HIV prevention
projects in 1996.
The majority of low adopters had a primary mission other than HIV:
these organizations included youth service centers, health clinics, church-
based groups, and providers that focused on serving a comprehensive range
of needs for a particular community, ethnic group, or social group. These or-
ganizations reported a relatively small client base (see Table I) and tended
to provide their services to the “general” population. These organizations
employed an average of five full- and part-time HIV prevention staff who
implemented about two prevention projects. Almost half of these organiza-
tions’ budgets were devoted to prevention.
Moderate adopters also tended to have a primary mission other than
HIV. These organizations tended to target substance users and youth. The
majority of providers in this group that were HIV-specific were primarily
care-focused organizations. That is, these organizations focused on provid-
ing services such as buddies, support groups, housing, food, recreation, and
treatment education to people living with HIV infection. The median client
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
Innovation in HIV Prevention 633
Table I. Organizational Characteristics of HIV Prevention Service Providers
Adoption status
Overall sample Low Moderate High Test of significance
(N=38) (n=13) (n=13) (n=12) (measure of association)
AIDS-related mission (%) 47 39 39 67 ns (Cramer’s ν=.263)
Ethnic minority mission (%) 29 23 31 33 ns (Cramer’s ν=.096)
Percentage located in urban setting 55 54 54 58 ns (Cramer’s ν=.042)
Target population (%)
General 45 69 23 42 X2=5.67, p=.06 (Cramer’s ν=.386)
Gays, bisexuals, lesbians, transgenders 34 39 15 50 ns (Cramer’s ν=.303)
Substance users 42 31 62 33 ns (Cramer’s ν=.285)
Youth 61 46 69 67 ns (Cramer’s ν=.213)
Median annual number of clients 3,000 1,074 8,000 9,075 X2=4.99, p=.08 (Spearman’s ρ=.249)
ED reports (mean no.) 2.8 1.9 3.5 3.0 ns (Spearman’s ρ=.343)
Hierarchy (mean no.) 1.6 1.8 1.5 1.5 ns (Spearman’s ρ=−.299)
Agency age (median years) 11 11 20 11 X2=5.44, p=.07 (Spearman’s ρ=−.074)
Staffing (median no.)
Fulltime staff 2.0 2.5 1.5 1.5 ns (Spearman’s ρ=−.085)
Parttime staff 1.0 1.5 0 1.5 X2=4.78, p=.09 (Spearman’s ρ=.089)
Unpaid staff 5.0 4.5 2.0 12.5 ns (Spearman’s ρ=.054)
Staff from target population (mean%) 67 59 54 87 ns (Spearman’s ρ=.113)
Organization budget (median $) 478,593 413,593 821,158 306,676 ns (Spearman’s ρ=−.149)
HIV prevention budget (median $) 56,121 94,654 36,113 54,241 K–W X2=5.96, p=.05 (Spearman’s ρ=−.179)
Mean % spent on HIV prevention 37 47 18 47 K–W X2=5.99, p<.05 (Spearman’s ρ=.042)
Prevention projects (mean no.) 2.2 1.8 1.5 3.3 K–W X2=6.75, p<.05 (Spearman’s ρ=.317)
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
634 Miller
base of these organizations was 8,000 clients per year. These organizations
were the oldest among those in the sample, with an average age of 22 years.
These organizations had larger budgets than high and low adopters, but de-
voted a significantly smaller percentage of that budget to prevention than
organizations in the other adopter groups. Moderate adopters reported a
small full-time prevention staff (median =1.5 people), no part-time preven-
tion staff, and few prevention volunteers. These organizations provided an
average 1.5 prevention projects.
The majority of high adopters were HIV-specific organizations. This
group included several HIV-specific organizations that were founded early
in the epidemic and several organizations that were replications of organi-
zations founded early in the epidemic. About half of the organizations in
this category of adopters targeted gay, lesbian, bisexual, and transgendered
populations and nearly two-thirds targeted youth. These organizations re-
ported the largest number of clients of any of the adopter groups, perhaps
because many of these organizations had street outreach efforts. These or-
ganizations also reported the greatest number of prevention volunteers of
any of the groups and the largest percentage of employees drawn from the
target population. These organizations spent nearly 50% of their budget on
prevention and provided the greatest number of prevention projects of all
groups, on average 3.3 (SD =2.1).
Innovation Characteristics
Although quantitative data are useful to understand what distinguishes
organizations that adopt externally developed programs from those that
do not, qualitative data may provide an in-depth understanding of how
organizations evaluate programs. We asked respondents to describe what
they look for in externally-developed programs and how their organiza-
tions’ make decisions about reviewing, adopting, and implementing such
programs.
All respondents reported having considered incorporating an exter-
nally-developed program, component of a program, or prevention practice
at some point in their history. Respondents typically reported considering
programs and practices developed by other CBOs.
Respondents employed five criteria to evaluate an externally-developed
program before making a decision to adopt it. Though no CBO would neces-
sarily apply all of these criteria to their evaluation of a program, 32% (n=12)
of the sample mentioned applying four of the five criteria and an additional
29% of the sample (n=11) mentioned applying three of the five criteria
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
Innovation in HIV Prevention 635
to specific decisions. These criteria provide insight regarding what mattered
most to CBO representatives in making program adoption decisions.4
Compatibility With Organizational Philosophy
CBOs (n=26; 68%) reported that is was important for externally-
developed HIV prevention programs to be congruent with their philosophy
about how prevention should be conducted. Indeed, 85% of moderate and
67% of low adopters mentioned incompatibility with organizational phi-
losophy as among the primary reasons that they had rejected externally-
developed programs. Agency standards and practices about issues such as
quality, appropriate language use, sexual explicitness, abstinence, and sex-
ual minorities were among the aspects of compatibility that respondents
mentioned:
We’ll put abstinence into all of our programs and we thoroughly believe that we’ll
support kids and hopefully give them the skills to be able to keep an abstinence-
based decision, but we just can’t buy into an abstinence-only program. (Interview
#20, high adopter)
Try not to put any weight on any option. Let the individual decide ... some organiza-
tions differ from us in that they want a certain approach advocated. Well, we don’t.
We deal with reality. (Interview #25, low adopter)
In addition to standards and practices, CBO representatives reported a
variety of organizational values that outside programs would need to espouse
to be considered organizationally viable. These values included an emphasis
on programs that were organic to their local communities and were perceived
by staff as culturally compatible with and respectful of the organization
and its target population. Low and moderate adopters commonly held the
view that externally-developed programs fell short of their organizations’
standards for enacting these values.
Curriculums seem to be written for upper to middle class people. They don’t seem to
be written for all people .. . and they seem to be written in a simple level, you know,
the questions are like so simple and it’s like, okay, we’ll see it but we’ll change it
so it’ll work. Cause it seems like you’re putting—if I use that with my youth, I’ll be
putting my youth down. (Interview #05, low adopter)
Organizations also expressed ambivalence about engaging in new ef-
forts that did not directly coincide with their current mission, improve upon
their present work, or fit with their present strengths or knowledge. Several
organizations reported there was a time when they “followed the money”
4Quotes where selected to be representative of the trends and meaning in the interview data.
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
636 Miller
and would add programs to meet the prevention needs of any target popu-
lation that was currently receiving attention from funding sources, but that
presently they preferred to focus on their areas of greatest experience and
strength in terms of types of programs and target populations. Moderate and
high adopters in particular emphasized the fundamental importance of keep-
ing their mission and history in mind when examining externally-developed
efforts.
...It would have to fit somehow within the focus of our organization already. What
we would probably want to do is do what we’re doing and do it better and make
sure we’re doing it well. And so we would only take on a prevention program that
kind of already fits with one of the things that we’re working towards. (Interview #10,
moderate adopter)
We have certain strengths and certain weaknesses, and we need to make sure that
we’re going with our strengths. (Interview #069, high adopter)
Does it enhance what we do? Like, is there any synergy created? And, you’re like,
“no, there’s none.” (Interview #32, moderate adopter)
Relevance to the Local Context
Inextricably associated with the notion of compatibility was the idea that
programs had to be well suited to the local cultural context. About 65% (n=
25) of the CBOs reported that programs must not only be compatible with
their organizational values but also fit well with local cultural and community
values. Relevance to local context was discussed by 77% of high adopters,
61% of moderate adopters, and 58% of low adopters.
Does it speak to their needs? Does it speak on their language? Does it contain
any components that are going to turn off the population that you have in mind?
(Interview #09, low adopter)
...not to clump everybody together like todos [all] Hispanics, you know....Ithink
you have to be very mulilateral, if that’s a word at all, unlike...the public health
model that the city has. (Interview #32, moderate adopter)
Organizations also expressed tremendous skepticism that a program
developed for one target population (e.g., the same risk group, but one from
a different geographic area or of a different ethnic background) was easily
transferred to another context.
What kind of groups have you been using? And give me the results. Why do you say
that it is good for this population based on what you’re talking about? (Interview
#13, moderate adopter)
We don’t do those [exercises about dating from safer sex workshops] anymore.
Why? One, because people weren’t showing interest anymore. And two, once again,
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
Innovation in HIV Prevention 637
these were models from—these were part of the [East Coast Organization] curricu-
lum....Westarted doing less kind of like—let’s come in and talk about being queer
kind of stuff. People aren’t into this big queer like they are in [East Coast City] as
much here...you know, Chicago is almost rural when you look at the grand scheme
of how you target prevention services. (Interview #16, high adopter)
Organizations emphasized that their local knowledge of their target
population and their ongoing relationships with the community were among
their most prized and well-protected resources. Programs that might nega-
tively affect the quality of their relationship with the community were not
favorably viewed.
Evidence Supporting Its Use
CBOs (n=20; 51%) expressed preferences for programs that they had
seen people enjoy and use. About 77% of moderate adopters, 42% low
adopters, and 38% of high adopters mentioned evidence. Evidence, as it was
discussed by respondents, was most often described in terms of witnessing
how target populations respond to the program. That is, CBOs emphasized
the projects and their implementation being observable. The vast majority
of those organizations that discussed evidence had seen the program that
they adopted (or rejected) in action and stated that how participants had
reacted to it was key to their adoption decision.
I could actually see what was going on, I could actually see the interaction and you
know, it’s one thing to have something down on paper to tell you do this, do that ,
you know, but it’s another thing when you see staff implementing these things to see
how it works or how it doesn’t work. (Interview #12, low adopter)
Evaluation data and observable outcomes were also valued by some
organizations, but it was the information gained from process data that re-
ceived the more substantial weight in making evaluative judgements about
programs. Part of what CBOs looked for was how adaptable the original
program was, given with whom and how it was originally implemented.
You’d just kind of have to look at what they report has been their outcome and
whether you think that the way they implemented it in their community would actu-
ally be a potential—would be plausible in your community....Youknow, it is not so
much reinventing the wheel as it is taking concepts that you’ve heard of elsewhere
and adapting it to your needs. (Interview #10, moderate adopter)
High adopters appeared to value behavioral science data more than
other adopter groups, frequently citing the importance of outcome and im-
pact studies of prevention programs.
Some statistics that would show that it either had—was able to encourage behavior
change in people and that’s hard to prove but that would be something worth looking
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
638 Miller
at because that’s I think the hardest thing to do is behavior change. (Interview #24,
high adopter)
These organizations frequently mentioned that they seriously consider
the guidelines and standards set by institutions such as the CDC and empiri-
cal findings from behavioral science. Organizations did not, however, accept
guidelines and empirical findings uncritically.
When you see that light bulb go off over their head, when you see that smile on
their face when they realize, ‘hey, you know, I can talk to my partner about using a
condom’. ...Whenyougetthat kind of feedback, I think that tells you if you’re being
effective more than any survey could. (Interview #09, low adopter)
In many cases, evidence was a matter of whether the program or strategy
reflected common sense.
Reputation was also a crucial source of evidence for many CBOs. CBOs
looked for programs that had been endorsed and used by their peers.
...You know, it’s not like we’re going to adopt any type of model that you know,
we hear about.... It has to have the right components. ... It has to have a good
foundation, it has to have a good reputation, a good acceptance. ...(Interview #07,
low adopter)
Feasible Given Available Personnel and Nonpersonnel Resources
CBOs (n=18; 47%) preferred programs that could be implemented by
small numbers of part-time and unpaid staff and that did not require signif-
icant money, time, space, or materials. About 61% of high adopters, 54% of
moderate adopters, and 42% of low adopters discussed feasibility. Creating
new programs that could not be easily incorporated into what a CBO was
already doing was characterized as unfeasible by many CBO representa-
tives. Perhaps as a result, CBOs discussed adopting outreach techniques and
efforts more frequently than any other type of prevention effort. Outreach
may be the most typical program that CBOs described having adopted in
part because it does not require additional or specialized space and the time
demands of outreach can often be met flexibly.
We feel we can incorporate that particular program [outreach] into what we’re al-
ready doing and we’ve seen other organizations do the same thing. So, that’s some-
thing that we can add very easily without having to worry about adding additional
staff or creating a whole new program. ...Because right now, with the five employees
that we have here now, we’re tapped out with what we’re doing now. (Interview #30,
moderate adopter)
If it’s a manageable, cost-effective program, and if there’s space, because we’re cur-
rently 21 people working in a space that comfortably houses 10. (Interview #06,
moderate adopter)
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
Innovation in HIV Prevention 639
The complexity and burdensomeness of implementing a program was
also part of judging its feasibility. Programs were often described as too large,
too long, and requiring too much added administrative work.
I mean every now and then we’ll get some kind of handouts of something on a
program that sounds real good except for, well, you’re gonna have to produce all this
paperwork in order to carry it out, or, gee, it’s gonna require a lot of staff hours to
do, you know, this component of it. (Interview #09, low adopter)
We adapted it [federally-produced curriculum]. It’s too much, and you don’t have
too much time. (Interview #13, moderate adopter)
Money dictated whether programs were deemed feasible more than
any other aspect of feasibility. CBOs described their ability to get monetary
resources for programs as the ultimate bottom line regarding what they could
and could not do. CBOs reported wanting to do more than they were able
to do, given current fiscal constraints. Many CBOs talked about programs
that they hoped to adopt, if they could secure the financial support to do so.
Our whole first year, I mean, we had like $3,300 to operate off of and that’s like, how
can you do a program with $3,300? (Interview #30, moderate adopter)
We had known for some time that we needed to do a new [program] and it was really
coming down to a question of how we were going to pay for it. (Interview #15, high
adopter)
Instability of funding also had a tremendous impact on what CBOs
perceived they could and could not do. CBOs described the need to plan
their prevention efforts in such a way that they could withstand frequent
changes in funders’ interests.
Because one year one population is hard hit by HIV infection or seroconversion and
all of a sudden they are the priority population, let’s say it’s IV use. And then the
next year its MSMs, so the funding tides change and your program, you know, it is
built completely around working with IV users that first year and then they switch
and say, ’Oh, it’s MSMs now. We’re defunding or slashing funding for everything that
was given for the IV user so we can put it over here to work with MSMs so then you
have to be diverse enough that you’ve got four or five legs to stand on. (Interview
#06, moderate adopter)
Fills a Gap in Local Services
About 45% of CBOs (n=17) expressed strong preferences to adopt
programs that would fill an existing gap in local area service provision. A
larger proportion of high adopters (46%) and moderate adopters (69%)
mentioned this criteria than low adopters (16%).
CBOs believed that a primary part of their role was to identify local
needs and develop programs that would fill those needs.
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
640 Miller
When we first identified that there was a need for something like this in the com-
munity, it stemmed from the fact that we work at an agency that serves people that
have HIV. And, the face of HIV had changed over the years from gay males to a
very large injectable drug using population. Identifying that the population existed
here in [town name] was one major step, as this is a very conservative community.
(Interview #02, moderate adopter)
Most of the prevention that ... has been done in the City ... was just targeted to
African Americans, Latin Americans, Hispanics, you know, Caucasians, and then the
Asians were just like set aside as others have been. (Interview #04, high adopter)
Maintaining uniqueness emerged as an important pressure on CBOs. A
primary reason for not adopting particular programs was that they might du-
plicate what another nearby organization was already doing. Indeed, CBOs
actively resisted engaging in efforts that might “step on the toes” of a peer
organization or that mirrored too closely what was already provided.
We’renot going to set out to do something that duplicates what another organization’s
already doing....I think that we are striving as a community and with the various
community-based organizations to, you know, work together to make up different
pieces of the pie and not the same piece of the pie. (Interview #10, moderate adopter)
You know, we’re not out to take someone else’s business ... if they have an AIDS
education program like this, that’s wonderful and we’resupportive but we don’t need
to duplicate it. (Interview #29, moderate adopter)
This idea was often bound up with the role of the CBO in responding
first and foremost to its community base.
Like everyone drives a car but the car is unique to that person who drives it. You
know, my car’s not the same as yours. They both do the same function but they’re
a little bit different because they got that personal touch. (Interview #06, moderate
adopter)
DISCUSSION
This study is among the first to address what criteria HIV-related CBOs
employ when making decisions about adopting externally-developed pre-
vention programs and to explore the relationships among organizational
characteristics and preferences for adopting externally-developed HIV pre-
vention programs. Our data provide preliminary evidence that organiza-
tional characteristics distinguish among HIV-related organizations with dif-
ferent innovation adoption profiles. Our data also provide partial support
for Rogers’ theoretical work (Rogers, 1995) regarding characteristics of
innovations that influence adoption decisions.
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
Innovation in HIV Prevention 641
Organizational Characteristics and Program Adoption
The organizations in our sample formed three distinct profiles: those
that had little experience adopting externally-developed programs, those
that had adopted components of programs, and those that had adopted entire
programs. These three profiles were distinguished by the level of resources
devoted to HIV prevention, centrality of HIV to the organizational mission,
and organizational age and size.
Contrary to previous research (e.g., Steckler & Goodman, 1989), or-
ganizations that had adopted externally-developed programs in their en-
tirety were small, relatively young, and had small actual prevention budgets
(median =$54,241). Despite their low level of resources to provide pre-
vention programs, these organizations’ strong ideological commitment to
HIV prevention appeared to encourage them to experiment with externally-
developed programs and stay abreast of cutting-edge programs. In contrast,
organizations that had only adopted parts of programs had characteristics
typically associated with program adoption, such as a large financial re-
source base. Perhaps because these organizations’ primary commitment was
to health concerns other than HIV, their ability and willingness to incor-
porate substantial, intensive HIV prevention programs into their service
repertoire was limited. Organizations such as these may be willing to ac-
commodate small efforts to prevent HIV among their clients, but appear
reluctant to make HIV prevention a major organizational foci. The low-
est adopter group, which was largely comprised of small, young, multipur-
pose organizations, shared many organizational characteristics with the high
adopters but provided fewer HIV prevention programs than high adopters
and were more likely to target populations generically in their HIV pre-
vention efforts. Perhaps because of the diverse array of unmet needs within
their target populations and their focus on underserved areas and groups for
whom few HIV-related prevention programs have been developed, adopting
externally-developed HIV prevention programs was uncommon.
Characteristics of Innovations
The organizations in this sample identified five characteristics by which
they would judge an external prevention program: (1) its degree of compati-
bility with organizational philosophy about HIV prevention, (2) its perceived
relevance to local culture, (3) evidence to support its use, (4) its feasibility,
and (5) its ability to fill a gap in what services are provided locally. The major-
ity of these characteristics are reflected in Roger’s notions of compatibility,
observability, complexity, and relative advantage.
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
642 Miller
In these data, several dimensions of compatibility emerged, including
compatibility with organizational philosophy and local culture. Organiza-
tions were willing to consider seriously programs that befitted their organi-
zational and local community culture and context, preferring programs that
delivered prevention messages in a manner consistent with their values and
language. The extent to which the program filled a gap in local services but
also did not overlap significantly with what was already locally provided also
emerged as a crucial issue in assessing a program’s compatibility with local
context. Competition over limited financial resources from few sources may
encourage CBOs to fill a niche in order to maintain funding (Garcia, 1999).
CBOs may perceive that ongoing financial support for their program is most
likely if potential funding sources see their programs as meeting a unique
need within some specified geographic catchment area. In addition, CBOs
may maintain positive working relationships with other CBOs by avoiding
offering programs and services that might lead to “turf battles.” It may also
be the case that maintaining a community-based organizational identity re-
quires CBOs to provide programing that is community-driven.
Feasibility of programs was another important criteria by which pro-
grams were judged. The CBOs in our sample preferred programs that were
compatible with their available personnel and nonpersonnel resources. Af-
fordability emerged as a key component of feasibility, an issue not clearly
addressed by Roger’s theory, though related to his notions of relative ad-
vantage and compatibility. For the CBOs in this sample, it was simply not
possible to adopt programs that were beyond the organizations’ means, sug-
gesting that regardless of the cost-effectiveness of any particular HIV pre-
vention program, its relative advantage and compatibility will decrease as
its absolute costs begin to exceed available funds. This finding seems intu-
itively obvious, but has practical implications for HIV prevention science.
Given the small size of the average CBO budget in this and other samples
(e.g., DiFranciesco et al., 1999), scientists may need to anchor their defini-
tion of what is an optimally cost-effective prevention program to the average
prevention budgets of potential users, in this sample about $55,000 in 1997!
Successful programs that have costs in excess of what a CBO can afford
are unlikely to be adopted and sustained in communities. At the same time,
prevention scientists are well positioned to address empirically what is the
minimum level of resources needed to provide a sufficient dose of preven-
tion to a community and to communicate those findings to funding sources. It
may be the case that funding sources lack adequate information about what
a successful prevention effort is likely to cost. Prevention scientists have an
important role to play in increasing understanding of what resources are
minimally necessary to prevent HIV infection. Prevention scientists may
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
Innovation in HIV Prevention 643
also need to play an active role in assisting organizations to secure adequate
resources to implement programs that have empirical support.
Unlike in Diffusion of Innovations Theory, complexity was discussed
by our respondents as an aspect of assessing a programs’ feasibility. Organi-
zations spoke about a program as too complex when its demands exceeded
the level of personnel, money, time, and space available for additional ef-
forts. Thus, although complexity was clearly an important characteristic of
programs, its affect on adoption decision-making was largely through the
implications of a specific program’s requirements on the feasibility of its
implementation within a given context.
Similar to what Rogers’ proposed (Rogers, 1995), for the CBOs in this
sample observability meant that CBO staff had watched a program’s target
audience respond positively to the program, had seen how to implement
and adapt it to suit local needs, and heard from peers or other information
sources viewed as credible that the program was good. The value placed
on implementation experiences may reflect the fact that among the primary
concerns of a service provider are how to carry out programs smoothly on
a day-to-day basis and to keep program consumers satisfied. Process data
and opportunities to site visit programs speak directly to observability in
this sense. At the same time, evidence of program performance or accrued
benefits in risk-reduction behaviors is also part of establishing that a specific
new program may have relative advantage over what is currently provided.
Certainly those CBOs that value outcome evaluation data depend upon
the information such data provide to judge whether externally-developed
programs ought to be considered for adoption. Nonetheless, for many of the
CBOs in our sample, evidence that concerned program processes was more
compelling than outcome-oriented evidence.
Two characteristics of innovations were seldom if ever mentioned by
respondents directly, relative advantage and trialability. Our respondents
appeared to judge an externally-developed programs’ relative advantage
by using other dimensions as criteria of merit. Relative advantage was de-
termined by a program’s compatibility, feasibility, complexity, observability,
and affordability. Relative advantage was discussed by respondents indi-
rectly. When respondents mentioned relative advantage directly, they typ-
ically did so in reference to common techniques and practices, but not to
entire programs or program components. For example, respondents talked
about specific outreach safety practices (e.g., working in teams) and client
intercept methods (e.g., intercept clients in the bathroom rather than at the
bar) as better than what they had previously done.
Respondents did not discuss the ability to try out a program on a short-
term basis as an important factor affecting adoption decisions. It is possible
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
644 Miller
that Rogers’ notion of trialability is most applicable to the types of tech-
nological and product innovations for which Rogers’ theory was originally
developed, such as cars, computers, and hybrid corn seed. Infrequent discus-
sion of trialability may also reflect the particular economic circumstances
of CBOs. Because CBOs are largely dependent on biennial and triennial
government contracts that require them to maintain a minimum level of
monthly service activity, CBOs may not have frequent opportunities to con-
sider pilot-testing or replacing entire programs. Trying projects out in small
scale form may not be practical, given the limited resources of CBOs and the
need to meet service delivery contract obligations. In addition, because the
Prevention Planning Group Process in many municipalities dictates what
types of intervention activities will be funded, CBOs may not perceive that
they have the latitude to explore new programs on a trial basis or that there
is a need for them to do so.
The results of this study should be considered in light of its limitations,
three of which merit specific mention. Although we labeled the adopter
groups “high,” “moderate,” and “low,” we believe that it is not appropriate
to characterize adoption status as linear. As a result, linear tests of asso-
ciation may not be ideally suited to these data and should be interpreted
cautiously. Our data would suggest that it is probably most appropriate to
understand each of these adopter groups as categories or types with several
subtypes within each group. Also, although our data suggest that adoption
patterns may be strongly influenced by a variety of organizational factors,
our data do not allow us to determine the relative importance of particular
characteristics in determining what type of adopter an organization might be.
Future research on the adoption of innovations should seek to clarify what
are typical organizational profiles of adoption and to better understand the
conditions that create such profiles.
A second key limitation of the study concerns the fact that our data re-
flect the views of a single representative of each organization. Although we
did interview the person who was perceived by the executive director as most
knowledgeable about the HIV prevention programs, those individuals were
not always necessarily employed at the time when the organization adopted,
rejected, developed, or modified all of the programs that were discussed in
the interview. These individuals’ retrospective accounts of adoption experi-
ences were therefore not always firsthand. Further, the experience of only a
single individual within the organization may not represent the experience
of others in the organization. Obtaining multiple perspectives within a single
organization could enhance understanding of how program adoption occurs
within organizations.
Finally, our data rely exclusively on the CBO representatives’ perspec-
tives regarding what program adoption is and whether that is something that
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
Innovation in HIV Prevention 645
their organization has or has not done. We did not assess whether CBOs had
in fact adopted a particular prevention program or whether they had done
so faithfully. These data therefore only reflect CBO representatives’ percep-
tion that the organization had adopted a program or ideas from an external
source. Future research in this area ought to examine whether there are dif-
ferences between organizations that implement programs with fidelity and
those that do not.
Despite these limitations, our data have important implications for the
field of HIV prevention and for theory concerning technology transfer of
programs. The results of this study would suggest that the CBOs that are
most likely to adopt prevention programs are small, HIV-focused organi-
zations with limited resources. These organizations may require substantial
technical assistance and resources in order to be able to implement and sus-
tain new prevention efforts. In addition to technical assistance and increased
resources, our results suggest that CBOs are more likely to adopt HIV pre-
vention programs if they have been designed with the typical CBO service
delivery context in mind, a context in which there are few personnel and
nonpersonnel resources and in which community responsiveness is highly
prized. Designing prevention programs that are informed by and responsive
to the context and values of potential users are important ways to begin to
encourage technology transfer between prevention science and practitioners
and develop programs that are likely to be used in ongoing service provision.
REFERENCES
Aiken, M., & Hage, J. (1971). The organic organization and innovation. Sociology,5, 563–582.
Altman, D. (1994). Power and community: Organizational and cultural responses to AIDS.
Bristol, PA: Taylor & Francis.
Altman, D. G. (1995). Sustaining interventions in community systems: On the relationship
between researchers and communities. Health Psychology,14, 526–536.
Backer, T. E., David, S. L., & Soucy, G. (Eds.). (1995). Reviewing the behavioral and science
knowledge base on technology transfer. Rockville, MD: National Institute on Drug Abuse.
Baldridge, J. V., & Burnham, R. A. (1975). Organizational innovation: Individual, organiza-
tional, and environmental impacts. Administrative Science Quarterly,20, 165–176.
Becker, M., & Joseph, J. (1988). AIDS and behavior change to reduce risk: A review. American
Journal of Public Health,78, 394–410.
Centers for Disease Control and Prevention. (1997). HIV/AIDS surveillance report (Rep.
No. 9). Atlanta, GA: Department of Health and Human Services.
Choi, K., & Coates, T. J. (1994). Prevention of HIV infection. AIDS,8, 1371–1389.
DiFranciesco,W., Kelly, J.A., Otto-Salaj, L., McAuliffe, T. L., Somlai, A. M., & Hackl, K. (1999).
Factors influencing attitudes within AIDS organizations toward the use of research-based
HIV prevention interventions. AIDS Education and Prevention,11, 72–86.
Fordyce, E. J., Williams, R. D., Surick, I. W., Shun, R. T., Quintyne, R. A., & Thomas, P. A.
(1995). Trends in the AIDS epidemic among men who reported sex with men in New York
City: 1981–1993. AIDS Education and Prevention,7(Suppl. 5), 3–12.
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
646 Miller
Freudenberg, N., & Zimmerman, M. A. (1995). AIDS prevention in the community: Lessons
from the first decade. Washington, DC: American Public Health Association.
Garcia, D. (1999). Innovation, prevention, and HIV: The influence of resources and relationships
on community organizations. Unpublished master’sthesis, University of Illinois at Chicago,
Chicago, IL.
Goldstein, E., Wrubel, J., Faigeles, B., & DeCarlo, P. (1998). Sources of information for HIV
prevention program managers: A national survey. AIDS Education and Prevention, 10,
63–74.
Hage, J., & Aiken, M. (1970). Social change in complex organizations. New York: Random
House.
Haynes-Sanstad, K., Stall, R., & Doll, L. S. (Eds.). (1999). Collaborative community research:
Partnerships between research and practice [Special issue]. Health Education and Behav-
ior,26(2).
Haynes-Sanstad, K., Stall, R., Goldstein, E., Everett, W., & Brousseau, R. (1999). Collaborative
community research consortium: A model for HIV prevention. Health Education and
Behavior,26, 171–184.
HIV/AIDS Resources. (1995). The national directory of resources on HIV infection/AIDS: The
professional’s reference (2nd ed.). Longmont, CO: Author.
Kalichman, S. C., Carey, M. P., & Johnson, B. T. (1996). Prevention of sexually transmitted
HIV infection: A meta-analytic review of the behavioral outcome literature. Annals of
Behavioral Medicine,18, 6–15.
Kruskal, W. H., & Wallis, W. A. (1952). Use of ranks in one-criterion variance analysis. Journal
of the American Statistical Association,47, 583–621.
Mantel, N. (1963). Chi square tests with one degree of freedom: Extensions of the Mantel-
Haenszel procedure. Journal of the American Statistical Association,58, 690–700.
Mantel, N., & Haenszel, W. (1959). Statistical aspects of the analysis of data from retrospective
studies of disease. Journal of the National Cancer Institute,22, 719–748.
Mayer, J. P., & Davidson, W. S. (2000). The dissemination of innovation. In J. Rappaport &
E. Seidman (Eds.), The handbook of community psychology (pp. 421–438). New York:
Plenum Press.
McCormack & Associates. (1997). The McCormack survey: A national survey of executive
directors of AIDS service organizations and gay and lesbian social service organizations.
Los Angeles, CA: Author.
Mesters, I., & Meertens, R. M. (1999). Monitoring the dissemination of an educational proto-
col on pediatric asthma in family practice: A test of associations between dissemination
variables. Health Education and Behavior,26, 103–120.
Miles, M. B., & Huberman, A. M. (1994). Qualitative data analysis: An expanded sourcebook
(2nd ed.). Newbury Park, CA: Sage.
Miller, R. L. (1995). Assisting gay men to maintain safer sex: An evaluation of an AIDS service
organization’s safer sex maintenance program. AIDS Education and Prevention,7(Suppl.
5), 48–63.
Miller, R. L., Klotz, D., & Eckholdt, H. M. (1998). HIV prevention with male prostitutes and
patrons of hustler bars: Replication of an HIV prevention intervention. American Journal
of Community Psychology,26(1), 97–131.
Morrissey,E., Wandersman, A., Seybolt, D.,Nation, M., Crusto, C., & Davino,K. (1997). Toward
a framework for bridging the gap between science and practice in prevention: A focus on
evaluator and practitioner perspectives. Evaluation and Program Planning,20, 367–377.
National Institutes of Health. (1997). Interventions to prevent HIV risk behaviors. NIH Con-
sensus Statement, Feb. 11–13,15(2), 1–41.
Office of Technology Assessment. (1995). The effectiveness of AIDS prevention efforts.
Washington, DC: Author.
Orlandi, M. A., Landers, C., Weston, R., & Haley, N. (1990). Diffusion of health promotion
innovations. In K. Glanz, F. M. Lewis, & B. K. Rimer (Eds.), Health behavior and health
education: Theory, research, and practice (pp. 288–313). San Francisco, CA: Jossey-Bass.
P1: GKW/RKP P2: GKW
American Journal of Community Psycgology [ajcp] PP195-341601 June 15, 2001 14:41 Style file version Nov. 19th, 1999
Innovation in HIV Prevention 647
Pett, M. A. (1997). Nonparametric statistics for health care research: Statistics for small samples
and unusual distributions. Newbury Park, CA: Sage.
Rogers, E. M. (1995). Diffusion of innovations (4th ed.). New York: Free Press.
Shediac-Rizkallah, M. C., & Bone, L. R. (1998). Planning for sustainability of community-based
health programs: Conceptual frameworks and future directions for research, practice, and
policy. Health Education Research,13, 87–108.
Steckler, A., & Goodman, R. M. (1989). How to institutionalize health promotion programs.
American Journal of Health Promotion,3, 34–44.
Strauss, A., & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures and
techniques. Newbury Park, CA: Sage.
Test Positive Aware Network. (1995). The 1995–1996 Chicago-area HIV/AIDS services direc-
tory. Chicago, IL: Author.
Thompson, J. D. (1967). Organizations in action. New York: McGraw-Hill.
Trickett, E. J. (1998). Context and culture in AIDS interventions: Ecological ideas for enhancing
community impact. Unpublished manuscript.
UNAIDS/World Health Organization. (1997). Report on the global HIV/AIDS epidemic,
December 1997. UNAIDS/World Health Organization Working Group on Global
HIV/AIDS and STD Surveillance.
