This article presents an organizing framework for developing countries to facilitate the development and implementation of educational initiatives to advance cancer care in an effort to effect global health in developing countries. The framework used to design this program was based on the classic work of Donabedian, who identified the structure, process, and outcome trilogy as essential components.30 Structure refers to the tools and resources that participants have at their disposal to accomplish their work and the organizational settings in which they work and practice. Structure encompasses the number, distribution, and qualifications of professional personnel as well as size, equipment, and geographic disposition of the facilities used to provide care. Structure goes beyond elements of production to include the manner in which the delivery of the program to provide care is organized, both formally and informally. Structure is characterized by the fact that it is relatively stable, it functions to produce care, and it influences the kind of care that is provided.
Process refers to a set of activities that go on within, among, and between participants and their clients. Technical and interpersonal aspects comprise the process component of the framework. Technical components refer to the application of science and technology in a way that maximizes benefits to health without increasing risks. The interpersonal domain refers to the social and psychological interaction between participants and clients.30
Outcomes represent the consequences of the process on the health and welfare of recipients. Specifically, Donabedian30(pp82-83) used the word outcome to mean a "change in a client's current and future health status that can be attributed to antecedent healthcare." Donabedian conceptualized outcomes to include physical as well as social and psychological function. In addition, he considered client attitudes, including satisfaction, health-related knowledge, and health-related behavioral change to be important outcome variables.
Application of the Model to the Cancer Program for Developing Countries
In this program, the structural elements included the National Cancer Institute of NIH, the funding agency, the 71 developing countries, the program faculty, and the participants representing their countries. The 2- to 3-day pre-conference workshops prior to an international cancer nursing meeting also represented structural variables. Process elements included the content of the cancer prevention and control program and the interactions that transpired among the faculty, participants, and personnel in their work settings and leaders in administrative positions in the developing countries. Outcomes of interest included the participants' knowledge, attitudes, implementation of program content, and, ultimately, behavioral changes related to improved health. A brief description of each of the structure, process, and outcome components is presented in Table 5.
Within such a framework, people are encouraged to organize themselves within their communities to improve their own health and the health of others. It is well recognized that there is enormous variability between countries (and even within countries) as to the rates and causes of morbidity and mortality.31 Similarly, it is recognized that interventions chosen at a global level cannot be responsive to such a variety of underlying causes, and an individualized approach is needed. One of the first steps in the process is to define the burden of disease within a country and identify interventions that have been proved to be effective.32 Once the structure and outcome components of the framework are established, then the participants need to operationalize the process. For this program, the process used to disseminate the content was through diffusion because it was directed at the individual level.
Diffusion occurs when "an innovation is communicated through certain channels over time among members of the social system."33(p14) Thus diffusion has several components.
1. It is a communication process that takes place through channels.
2. It is directed to specific members of the social system.
3. It introduces something new into the system that reduces uncertainty about some key activity within the social system.
Innovation diffusion was developed by Rogers,33 who conceived the individual as the adopter. We further operationalized the process component to include diffusion of the innovator.
An individual's decision to adopt an innovation is usually reached in a series of four steps. In the first step, knowledge, targeted individuals become aware of the innovation and begin to associate it with needs or activities to which it is relevant, and to an agenda, either personal or organizational. In knowledge step, the complexity of the innovation and information about how it can be used are important. Complexity influences the adopter's assessment of how easily it can be implemented. It also refers to the understandability of the underlying principles that govern how the innovation is used and under what circumstances. Clearly, professional judgment is required to assess whether the innovation is sufficiently advanced and tested to be considered for implementation. Another characteristic of the innovation that is important at the knowledge step is its compatibility or its relevance to other activities that are part of the core tasks of the organization. The important sources of information tend to be objective and impersonal.
The second step in the process is persuasion. At this step other features of the innovation become significant, namely, its observability and technical advantage relative to standard practice. If the innovation is complex and apparently varying from accepted ideas, its justification by significant individuals in the profession may resolve or reduce uncertainty. However, the motivation to implement such a change will depend upon evidence that individuals such as those in the target audience have experienced success in implementing it. Thus, at this stage the local influential opinion leaders in that community who are well known and viewed as successful are most likely to be able to persuade others to try the innovation.33,34 The effects of the innovation are assessed through tangible results. Traditionally, these have included reduced mortality or morbidity, improved access to critical resources, improved cost/ benefit ratios, or a combination of these.
The third step in the process is the decision about whether the innovation will actually be implemented. Innovations that can be adopted on a trial basis are more likely to be adopted. The trialability is determined by whether the target audience has the resources to implement the innovation and how permanent the initial decision has to be. Thus, if the innovation can be tried at no great risk to the adopter, and if there are resources available to the initiator or the organization to support trial use, it is more likely to be adopted than if such resources are scarce and/or the decision once made is difficult to reverse. The decision to adopt an innovation occurs over time and leads to the fourth step, confirmation. Because adoption is an ongoing process, this final step is not fully attainable. Its incorporation in the model serves to emphasize that the adoption of an innovation is always conditional on the basis that the innovation makes a contribution to the core activities of the organization or the individual making the decision to adopt. Thus, adoption implies an initial decision, which then must be confirmed by continued experience, leading to sustainability. There is the possibility that the adopter will revert to earlier practice or replace the innovation with something even more innovative.
In order for individuals and communities to adopt the innovation and content of the program to bring about change, the formation of partnerships of key participants within developing countries is needed so collaboration evolves. In Figure 2, a description of each component within the framework and how it has been operationalized and measured for its impact is summarized.