The adoption of a prevention database by

health promoters

Group 5
Ravian Arp (r.p.arp@students.uu.nl) 3240959
Björn Fischer (b.fischer@students.uu.nl) 5708931
Simon Goes (s.goes@students.uu.nl) 5517761

Course: Consultancy Project (GEO4-2252)

Master program: Innovation Sciences
Supervisor: dr. Jan Faber (j.faber1@uu.nl)

Date: 29th of June, 2016

Table of contents
1. Introduction 1
2. Theory 2
2.1 Dependent variable: Willingness to adopt 2
2.2 Independent variables 2
2.2.1 Relative Advantage 3
2.2.2 Compatibility 3
2.2.3 Complexity 4
2.2.4 Trialability 4
2.2.5 Observability 5
2.2.6 Context-related factor: communication channels 6
2.2.7 Conceptual model 7
3. Research methodology 7
3.1 Research design 7
3.2 Data collection 8
3.3 Sampling strategy and case selection 9
3.4 Operationalization 9
3.5 Data analysis 11
3.6 Research quality indicators 11
4. Results 12
4.1 Characteristics of participating municipalities 12
4.2 Key Findings 12
4.2.1 Relative Advantage 12
4.2.2 Compatibility 13
4.2.3 Complexity 14
4.2.4 Trialability 14
4.2.5 Observability 15
4.2.6 Communication Channels 16
4.2.7 Social involvement 17
5. Discussion 17
5.1 Theoretical implications 17
5.2 Managerial implications 19
5.3 Limitations 19
6. Conclusion 20
References 21
Appendix A. Operationalization table 25
Appendix B. Interview questions 27
Appendix C. Importance of independent variables & indicators 30
1. Introduction
Healthcare is a growing economic sector with huge future development potentials (Watson, 2006;
WHO, 2013). It is generally characterised by a high intensity of new technological developments
(Cohen et al., 2004). Also in the Netherlands, the healthcare sector is in continuous transition (Schäfer
et al., 2010). Demographic changes and an aging population (CBS, 2009) lift the demand for new and
better healthcare services (Pohlmeier & Ulrich, 1995). Therefore, many politicians are worried that the
expenditures in the healthcare sector become too high for the public (Getzen, 1992; Polder et al., 2006;
OECD, 2015). Hence, the pressure on healthcare organisations is high to develop new medical
practices and services that have both, a better quality to satisfy the needs of society, and, reduce the
costs of healthcare to comply with the requirements of politicians (Howie & Erickson, 2002; Jadad &
Delamothe, 2004). However, it is challenging for health organisations to create new innovations and to
successfully bring them to the market (Länsisalmi et al., 2006). For example, the development of
health technologies needs to be aligned with several ethical concerns (Collier, 1994) and is therefore
strongly regulated by the government (Faulkner & Kent, 2001). This in turn creates uncertainties for
health organisations about the commercial success of their innovations (McClellan, 1995; Plsek,
2003). In sum, it is a difficult task for healthcare organisations to deliver health services and products
that are both of significant value to society and can decrease health expenditures.
One of the ways in which healthcare organisations can decrease costs and at the same time
improve the health standard of people is prevention (Russell, 1993). Prevention measures can provide
new knowledge to citizens about healthier lifestyles and thereby help them to become more health-
conscious (Jayanti & Burns, 1998). At the same time, if citizens can be convinced to live a more
health-conscious life, some illnesses could be prevented before they occur. In this vein, future costs for
additional treatment can be avoided (Maciosek et al., 2010). In the Netherlands, one organisation that
is responsible for healthcare prevention is the national institute for health and the environment
(RIVM). As a public organisation, the RIVM uses new insights from scientific research to provide and
renew policy advice for different governmental authorities (RIVM, 2016). One department of the
RIVM, the Centre for Healthy Living, is primarily concerned with promoting lifestyle interventions by
working together with health promotion institutes and by providing health promotion professionals
with planning instruments and communication materials (Centre for Healthy Living, 2016a).
The Centre for Healthy Living has developed a database which contains information and
suggestions on how to prevent different health problems based on current theoretical and empirical
evidence (Centre for Healthy Living, 2016b). The database serves various prevention goals, for
instance the prevention of smoking and alcohol abuse. For example, the idea is that the information
provided in the database could enable people to learn more about bad consequences of smoking, and in
this manner make people smoke less. In turn, severe health diseases that would follow from smoking,
such as lung cancer, could be prevented on a much larger scale and hence the money spent on such
diseases could be decreased. In general, the Centre for Healthy Living thinks that the database can
significantly help improve the health of the Dutch public and in turn decrease the expenditures on
medical treatments. The intended use of the database is for health promoters such as local public
health authorities at the municipality, general practitioners and health professionals at schools. Their
task is to promote the information contained in the database to the general public. For example, local
public health authorities could promote healthy living by starting anti-smoking campaigns based on
insights from the database. However, at the moment, the database is used only by a limited number of
health promoters. To resolve this innovation problem, the Centre for Healthy Living is interested in
why their database is only used on a limited basis and how it can improve the adoption of their
database. Therefore, the goal of this paper is to identify reasons for why the willingness to adopt the

1
database is currently low, and to suggest measures that RIVM could undertake to improve it.
Therefore, the research question is:

What factors influence the willingness of health promoters to adopt the intervention database as
developed by RIVM and in turn can help the RIVM improve the adoption of this database?

This paper seeks to identify reasons for why the adoption of this database is currently low and to
suggest ways to improve it. If the adoption of the intervention database would be increased, the public
would have a better access to measures that could be undertaken to prevent diseases or sicknesses.
Therefore, the societal contribution of this paper would be an increased health standard of the Dutch
public and a possible decrease in the expenditures on health treatments through the successful
implementation of the intervention database as developed by the RIVM.
Furthermore, this study contributes to the existing theoretical literature on the adoption and
diffusion of innovations in the healthcare sector. In the healthcare sector, some studies have
investigated the adoption of technologies such as electronic health records (Villalba-Mora et al., 2015)
and personal digital assistants (Lu et al., 2005). However, to our knowledge, no research has been
done yet on the adoption of an intervention database by health promoters. Thus, the theoretical
contribution of this paper would be to examine the extent to which adoption theory is applicable to the
adoption and diffusion of a prevention database among health promoters.
This report is outlined as follows. Section 2 gives an overview of the theoretical concepts that
are applicable to explain the lacking adoption of the database. Section 3 describes our research
methodology, including the operationalization of our theoretical concepts as well as the derivation for
the interview questions. Section 4 reports the results of our study. In section 5, the implications and
limitations of the results are discussed. Section 6 concludes.

2. Theory
2.1 Dependent variable: Willingness to adopt
The intervention database of the RIVM is open and available to anyone, i.e. the database has already
been launched to the market. The RIVM currently faces the problem that this database is only adopted
by a small number of health promoters. For this purpose, Rogers’ (1976) theory of adoption and
diffusion is particularly suited, since it explains how and why innovations are adopted by different
customer segments of a social system. The author argues that diffusion is the “process by which an
innovation is communicated through certain channels over time among the participants in a social
system” (Rogers, 2010, p.11). The notion of a social system refers to a “set of interrelated units that
are engaged in joint problem solving to accomplish a common goal” (Rogers, 2010, p.23). According
to Rogers (2010), an innovation diffuses through a social system as individual members decide
whether or not to adopt a particular innovation. In line with this sentiment, the adoption of an
innovation is defined as an individual’s “decision to make full use of an innovation as the best course
of action available” (Rogers, 2010, p.177). As adoption is an individual choice, it is directly affected
by the extent to which people are willing to adopt it. The willingness to adopt refers to the intention of
potential adopters to decide in favour of a new innovation. In the case of RIVM, the health promoters
are concerned with this decision.

2.2 Independent variables

Several factors have been identified that influence the willingness to adopt. Many studies highlighted
that five perceived key characteristics of an innovation are crucial in determining the adoption

2
decisions of individuals (Moore & Benbasat, 1991; Greenhalgh et al., 2004; Rogers, 2010). These
innovation characteristics are generally summarised as: compatibility, complexity, relative advantage,
trialability and observability (Rogers, 2002; 2010). For the specific case of the RIVM, those
innovation characteristics might influence the willingness of healthcare promoters to adopt the
intervention database. Therefore, this study investigates the impact on the willingness to adopt through
these five perceived key innovation characteristics. Furthermore, the broader communication system is
also important, since this determines whether people can actually become aware of the innovation
(Rogers, 2010). For our case, this means that communication channels need to be in place that make
the health promoters aware of the characteristics of the intervention database. Therefore, the context of
the existing communication channels is also taken into account as a separate independent variable.

2.2.1 Relative Advantage

The relative advantage of a new technology or innovation refers to its perceived superiority over
preceding technologies and ideas (Rogers, 2002). For evaluating the relative advantage of a new
technology or innovation, it is not important whether the new innovation is objectively superior to
others. Rather, what matters is the perception of potential adopters that the new innovation has a
considerable advantage over others. We thus follow Rogers (2002) and define the relative advantage
of an innovation as “the degree to which an innovation is perceived as better than the idea it
supersedes” (p.990). Adopters evaluate the relative advantage of an innovation based on a ratio of the
expected costs and benefits of adopting a new innovation (Rogers, 2010).
The relative advantage of an innovation is constituted of several dimensions. These may refer
to economic advantages such as higher efficiency and lower costs, user-advantages such as a better
user friendliness, as well as social advantages like an improved social status or image (Rogers, 2010).
Multiple studies have been conducted that investigate the impact of the different dimensions of the
relative advantage of a new innovation on the willingness to adopt. For example, Fliegel & Kivlin
(1966) found that American farmers were more willing to adopt innovations that had the relative
advantage of being least risky and most rewarding. In a study of Singapore consumers by Gerrard &
Barton Cunningham (2003), it is stressed that more users adopted the service of internet banking due
to its relative user-friendliness as compared to other banking services. In general, all studies conclude
that there is a positive relationship between the perceived relative advantage of a new innovation and
the willingness to adopt it (Rogers, 2010).
The studies above show that potential users are more willing to adopt innovations that have a
high perceived relative advantage, for example in terms of their economic and social benefits. For the
specific case of RIVM, this means that the healthcare promoters will be more willing to adopt the
intervention database if its level of perceived relative advantage is greater. Consequently, the
following hypothesis is formulated:

H1: The perceived relative advantage of the intervention database of the RIVM has a positive effect on
the willingness of health promoters to adopt the database.

2.2.2 Compatibility
Compatibility is defined as the “degree to which an innovation is perceived as being consistent with
the existing values, past experiences, and needs of potential adopters” (Rogers, 2002, p.990).
According to Tidd & Bessant (2013), there are two aspects of compatibility. First, compatibility may
refer to the compatibility with existing practices and skills of the potential adopters. In order to be
compatible, new innovations should be in line with the prevalent production environment in which
they are introduced. Second, compatibility may refer to compatibility with with existing values and

3
norms. To be compatible, new innovations should also match existing values of the adopters and
organisations in general.
Several studies have investigated the impact of perceived compatibility of an innovation on
the willingness to adopt. For example, Tornatzky & Klein (1982) show in their meta-study of other
empirical publications that perceived compatibility is one of the most relevant variables predicting the
adoption of new innovations. In a different study, Carter & Belanger (2004) confirm that higher levels
of perceived compatibility lead to increased intentions to adopt electronic government initiatives.
Overall, most studies indicate that there is a positive relationship between the perceived compatibility
of an innovation and the willingness to adopt it (Rogers, 2010).
The studies above show that potential users are more willing to adopt innovations that have a
high perceived compatibility, both in terms of their compatibility with existing practices and their
compatibility with existing values. The literature indicates that the adoption increases for innovations
that are perceived to be compatible. For the specific case of RIVM, this means that a higher level of
perceived compatibility of the database with existing values and practices will prompt healthcare
promoters to be more willing to adopt the intervention database. We thus hypothesise:

H2: The perceived compatibility of the intervention database of RIVM with existing skills, practices,
values and norms has a positive effect on the willingness of health promoters to adopt the database.

2.2.3 Complexity
Complexity is defined by Rogers (2002, p.990) as “the degree to which an innovation is perceived as
difficult to understand and use”. That is, innovations can also be distinguished based on whether they
can be comprehended easily by adopters, or whether they require the adopter to develop specialist
knowledge to understand and make use of them. According to Damanpour & Schneider (2009), the
complexity of an innovation may refer to two different facets. On the one hand, it can denote the
extent to which an innovation is new to the adopters. On the other hand, it can also represent the
intellectual difficulty associated with understanding an innovation. Both aspects jointly influence the
degree to which an innovation is perceived to be complex.
There are several studies that have sought to understand the impact of the complexity of an
innovation on the willingness to adopt it. Jo Black et al. (2001) performed a qualitative study among
three focus groups about the adoption of internet banking products. Their research showed that the
people who felt that the complexity was high were more hesitant to adopt internet banking. People
who perceived a relatively low complexity were more willing to start using internet banking. In
another study, Lee (2004) showed that nurses were less likely to adopt a health innovation when the
complexity was higher.
The studies above show that potential adopters are more willing to adopt when the perceived
complexity is lower (Rogers, 2010). Therefore, the complexity of an innovation negatively influences
the willingness of people to adopt it. Regarding the case of RIVM, this means that a higher perceived
complexity of the intervention database will cause health promoters to be less willing to adopt it. From
this the following hypothesis can be derived:

H3: The perceived complexity of the RIVM intervention database has a negative effect on the
willingness of health promoters to adopt the database.

2.2.4 Trialability
Trialability is defined by Rogers (2002, p.990) as “the degree to which an innovation may be
experimented with on a limited basis”. Thus, trialability refers to the ability of a potential adopter to
find out whether the innovation will serve its needs and functions as expected.

4
 In the literature, one recurrent argument is that providing potential adopters with the ability to
vigorously test the technology might help potential adopters to become acquainted with the product
through learning-by-doing (Tidd & Bessant, 2013). In turn, this increased familiarity might raise the
people’s confidence in the product, decrease uncertainties and thereby increase their willingness to
adopt it (Black et al., 2007). A few studies have been conducted that substantiate this positive
relationship between trialability and the willingness to adopt. Ducharme et al. (2007) examined the
effect of trialability in the adoption of substance abuse treatment. They showed that trialability can
positively influence the willingness to adopt a new substance abuse treatment. Furthermore, a
quantitative study about the adoption of computer technology in Saudi Arabia by Al-Gahtani (2003)
shows a strong positive relationship between trialability and the willingness to adopt computer
technology.
These studies both prove the same mechanism of trialability and the willingness to adopt.
With an increased trialability, the potential users can familiarise themselves with the product,
independent on whether it is a computer technology or health treatment. This increased familiarity in
turn increases the perceived trust in the product, and therefore also the people’s willingness to adopt.
For the specific RIVM case, this means that a higher level of perceived trialability will increase the
health promoters’ willingness to adopt the intervention database. Consequently, one might
hypothesise:

H4: The perceived trialability of the RIVM intervention database has a positive effect on the
willingness of health promoters to adopt the database.

2.2.5 Observability
Observability is defined by Rogers (2002, p.990) as “the degree to which the results of an innovation
are visible to others”. In other words, an innovation’s observability is about the ability of the adopter
to observe what the new technology does, and what its benefits are. The observability is higher if more
users of an innovation exist that communicate the benefits of the innovation to others. The reason for
this is that, as more users exist who communicate about the benefits of an innovation, more potential
adopters are communicated with and can thereby see the benefits of the innovation (Tidd & Bessant,
2013). This is also referred to as the “epidemic model” (Rogers, 2010).
The usual argument is that because people find out about the benefits of an innovation
through other adopters, whom they usually trust, they are then more inclined to also adopt the
innovation (Rogers, 2010). A number of studies corroborated this argument. In her article on the
adoption of health technologies for nurses, Lee (2004) shows that nurses were more willing to adopt
healthcare technologies when other nurses communicated their benefits. Moreover, Jo Black et al.
(2001) show that if observability of internet banking services is higher, the focus groups are more
willing to also adopt the service.
The abovementioned studies reveal a positive relationship between observability and the
willingness to adopt an innovation. The common mechanism is that when the observability is higher,
more people find out about the benefits of an innovation. As a consequence, they are more willing to
adopt the innovation. For the specific case of the RIVM, this means that when more healthcare
promoters observe the benefits of the prevention intervention database, they will be more willing to
adopt it. Therefore, we hypothesise as follows:

H5: The observability of the RIVM intervention database has a positive effect on the willingness of
health promoters to adopt the database.

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2.2.6 Context-related factor: communication channels
So far, the five perceived characteristics of an innovation have been discussed regarding their effect on
the willingness of health promoters to adopt the database. These are also referred to as “adoption
factors”. However, these factors refer to the perceived knowledge about an innovation. They do not
consider how this knowledge is communicated. This is a crucial problem, because people can only
become aware of the five abovementioned characteristics of an innovation if this information actually
reaches them (Rogers, 2010, p.222). According to Rogers (2010), the existing communication
channels are responsible for the way the knowledge about the characteristics of an innovation spreads.
Therefore, the existing communication channels also need to be taken into account. Rogers (2010)
defines a communication channel as “the means by which messages get from one individual to
another” (p.18). For the specific case of the intervention database, the RIVM is responsible for
communicating about its characteristics. Consequently, communication channels are analytically
different from the adoption factor observability. While observability describes the extent to which
users communicate their opinion about the results of an innovation, communication channels refer to
the way the RIVM communicates the knowledge about its database. As argued above, the
communication channels are a crucial prerequisite for people to become aware of the innovation
characteristics (Rogers, 2010). Therefore, in the following paragraphs, we specifically discuss the
effect of the existing communication channels as utilised by the RIVM on the awareness of the
innovation characteristics of the database. Two dimensions are important for communication channels
to effectively affect awareness.
One relevant dimension is the communication network of the RIVM (Rogers & Kincaid,
1981). Communication networks “consist of interconnected individuals who are linked by patterned
flows of information” (Rogers, 2010, p.27). According to the literature, the structure of the existing
communication network can have a strong impact on the awareness of innovation characteristics. For
example, one study by Abraham and Rosenkopf (1997) indicates that a higher number of network
channels and other aspects of the communication network increase the awareness of the innovation
characteristics by potential adopters. Other studies also have shown that there is a positive effect of
network factors on the awareness of the innovation characteristics. For instance, Valente (1995)
proved that network closeness increases the awareness of the innovation characteristics. Furthermore,
McPherson et al. (2001) and Rogers (2010) argue that communication through a communication
network is more effective when source and receiver are homophilous, i.e. when they are similar in
terms of their beliefs, norms and mutual understandings. For the specific case of the intervention
database, this means that the RIVM needs to consider various communication network factors. From
this it follows that in order to increase the awareness of health promoters about the characteristics of
the database, the RIVM needs to implement its communication channels by taking these network
factors into account.
A second important dimension is the utilisation of the communication channel by the RIVM
itself. One recurrent argument in the literature is that well utilised communication channels can
increase the awareness of the innovation characteristics (Wejnert, 2002). In our case, the RIVM is the
actor that can actively influence the awareness of the characteristics of the database (Latour, 2005).
Several studies have shown how an actor can utilise its communication channels. For example, Rogers
(2010) and Abraham and Rosenkopf (1987) show that a broad use of both interpersonal and media
channels has a positive influence on the awareness of innovation characteristics. Furthermore,
Rothwell and Wissema (1986) as well as Peter et al. (1999) reveal that a good marketing strategy
targeting all relevant audiences increases their awareness regarding the characteristics of an
innovation. Moreover, Rogers (2010, p.373) argues that people are more aware of the characteristics
of an innovation if the organisations that promote it put in a larger effort and time dedicated towards

6
communication about it. From this it becomes clear that the the RIVM needs to utilise its
communication channels well to increase the awareness of health promoters about its database.
In sum, both network factors as well as the RIVM as an actor have a strong influence on the
awareness of the characteristics. As argued above, if the communication channels are well utilised by
the RIVM and if they are well implemented by the RIVM by considering the various network factors,
they work more effectively. In turn, the innovation characteristics of the database can be perceived
more easily. We therefore suggest the following hypothesis:

H6: Communication channels that are utilised and implemented by the RIVM have a positive effect on
the awareness of the adoption factors by health promoters.

2.2.7 Conceptual model

These hypotheses can be summarised into the following conceptual model (Figure 1).

Figure 1: Conceptual model

3. Research methodology
3.1 Research design
The nature of our research is deductive, because we use theoretical insights from existing scientific
literature to derive the independent variables that we assess within this research (Bryman, 2012). The
purpose of our research is to empirically explain why the adoption of the intervention database by the
RIVM is currently low and to derive a strategy for the RIVM to improve the adoption of this database.
Hence, our research has a designing function. (Oost, 2003). For this purpose, a qualitative approach is
most appropriate, since it allows us to investigate causal explanations for the low adoption of the
RIVM database (Silverman, 2006). Since we intend to investigate causal explanations for the case-
specific issue of the adoption of the RIVM database by multiple different municipalities, we employ a
multiple-case study design (Bryman, 2012, p.75). We employ this research design, because it
explicitly takes the contextual differences of each case into account (Yin, 2013). This is especially
relevant in our study, since according to Rogers (2010), the context of the existing communication
system plays an important role in the adoption of specific innovations. As mentioned above, we seek
to understand why municipalities choose to adopt or not adopt the RIVM database. Therefore, the unit
of analyses for our study are the different municipalities.

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3.2 Data collection
In order to collect our data, we conduct multiple interviews. In choosing the respondents for our
interviews, we follow the key informant approach (Morgan & Hunt, 1994). This means that we
conduct interviews with the most knowledgeable people regarding health care and prevention at the
municipality. According to the RIVM, the direct adopters of the intervention database are the local
public authorities at the municipalities. They are also responsible for stimulating all other health
promoters within the municipality to use the database, which makes them specifically knowledgeable.
Thus, our selected interviewees are local public authorities that are responsible for the promotion of
healthcare technologies within the municipalities (Bryman, 2012). Hence, the unit of observation are
the local public authorities at the different municipalities. In most cases, we visit the municipalities
personally to conduct face-to-face interviews, but some interviews are conducted by means of
telephone interviews.
Empirically, we conduct the interviews based on a semi-structured interview schedule
(Bryman, 2012). This is because of two reasons. First, our interview schedule needs to be flexible so
that we can react to certain answers given by the interviewee (Perkins et al., 2004). This enables us to
ask follow-up questions and change the order if necessary (Bryman, 2012). Second, the schedule also
needs some structure to measure the various theoretical concepts from the literature. By means of a
semi-structured interview schedule, we are able to achieve both. To conform with our semi-structured
approach, our interview guide follows a general schedule that involves all relevant theoretical concepts
to answer our research question, but is flexible enough to change the order or ask additional questions
for further elaboration by posing questions such as “why?” after each question (Bryman, 2012). The
interview guide contains both open questions as well as a series of factors that are scored by the
interviewee. The interview guide is attached in Appendix B. These questions specifically address
health promoting local authorities at municipalities. The interview starts with a number of factsheet
questions after which some general questions are asked in order to put the interviewee at ease
(Bryman, 2012). After this, question 3a asks whether the municipality has heard about the database or
not. Based on this, our interview proceeds in different ways. If the municipality did hear of the
database, question 3b first asks whether or not the municipality has adopted the database.
Subsequently, question 4 asks openly what features of the database are perceived to be strengths and
weaknesses, to to find out whether the interviewee comes up with the adoption factors by himself so
that we can gauge the relative importance of our independent variables. Subsequently, we ask
specifically about the importance of each independent variable that we identified in the theory section.
The structure for the questions for each independent variable is as follows. First we pose an open
question to find out whether the interviewee recognises this independent variable to be important and
to identify what aspects of this variable the interviewee mentions by himself to be important (a.). If the
specific independent variable is recognised by the interviewee as important, we complement the
aspects the interviewee mentioned by himself and ask a number of checklist questions to evaluate
specific indicators for the independent variable that are derived in our operationalization (b.). If the
municipality did not hear of the database, we skip the questions about the adoption factors and directly
ask about the quality of the communication channels with RIVM and other organisations (question
10). In this vein, we aim to find out why the municipality did not hear about the database yet and what
role the RIVM plays in this respect. Furthermore, a municipality that did not hear about the database
might still know what features or aspects are important for the health promoters to adopt the database.
Therefore, question 11 specifically addresses interviewees that did not hear about the database to find
out what factors they deem to be important for adoption. Conducting the interviews lasts an average of
30 minutes.

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3.3 Sampling strategy and case selection
As local authorities at all municipalities in the Netherlands may be potential adopters of the
intervention database by RIVM, the intended population of this research consist of all the
municipalities in the Netherlands. Regarding our sampling strategy, we start our case selection with
local authorities at municipalities that the RIVM recommended to contact. The reason for this is that
the RIVM has many contacts with local public authorities across the Netherlands. In a first step, these
local authorities are contacted via e-mail with the request to conduct an interview. To increase the
response rate, the e-mail contains a reference to the RIVM and a short outline of the significance of
this study to the work of the local authorities regarding prevention in healthcare. Whether or not a
respondent is included in our sample, however, depends on his or her willingness to participate in this
study, which is why the first step consists of a convenience sampling strategy (Bryman, 2012). In a
second step, after conducting the interviews, the interviewees are asked for further contacts. We do
this because we expect that the local public authorities themselves have a good social network with
other municipalities since they are active in similar fields and positions. We therefore pose a question
for further contacts in the end of our interview guide (Appendix B). Hence, we also use snowball
sampling (Bryman, 2012). Following these sampling strategies, we select a sample of nine
municipalities. In each municipality, one local public authority is interviewed that is responsible for
health promotion.

3.4 Operationalization
Table 1 in Appendix A summarises the operationalization of the main variables. The different
dimensions of the different concepts stem from theoretical arguments by Rogers (2010) as outlined in
section 2. The indicators for the various concepts are mostly derived from previous research
conducted by Wejnert (2002), Fitzgerald et al. (2002) and Rogers (2010). The measurement consists of
open questions that follow from the indicators. The following paragraphs explain the link between the
selected indicators and the different dimensions from the theory. The choices of indicators that are not
straightforward are explicitly elaborated on.
For our case of the RIVM, the indicator for the dimension of the dependent variable “level of
willingness to adopt” is the potential willingness of people to adopt this intervention database of the
RIVM. Regarding the three dimensions of the independent variable “relative advantage”, the
indicators for the database of RIVM are as follows. The indicators for the level of perceived economic
advantages are the expected cost reduction and the expected increase in efficiency by using the
database (Wejnert, 2002; Fitzgerald et al., 2002). Furthermore, the level of perceived usefulness is
indicated by the perceived user-friendliness of the database to the local public authorities and the
expected contribution of the database to the issue of health intervention (Fitzgerald et al., 2002). The
perceived scope of the prevention measures can increase the level of perceived usefulness, because the
broader the prevention suggestions from the database can be applied, the more useful it is perceived by
the practitioners. Moreover, the level of perceived social advantages is indicated by the perceived
contribution to the image of the local public authorities (Rogers, 2010). The idea is that the local
public authorities may perceive the database as contributing to their own image when they expect the
patients to appreciate the advice given from the database.
Regarding the independent variable “compatibility”, the first dimension, the level of perceived
compatibility with existing practices and skills of the potential adopters, is measured based on four
indicators. First, it is important for a high level of compatibility that the database does not force the
potential adopters to change their current skills (Rogers, 2010). Therefore, the first indicator measures
the expected extent to which health care promoters need to make adjustments of their practices and
skills. Secondly, it is also important for a high level of compatibility that those changes that need to be

9
made can be implemented within the current practices (Rogers, 2010). Thus, the next indicator taps
into the extent to which changes of existing skills and practices are difficult to implement. The second
dimension, the level of perceived compatibility with existing values and norms of potential adopters, is
indicated by the perceived fit of the database with existing healthcare morals and norms.
With respect to the independent variable “complexity”, the first dimension, the level of
perceived newness of the database, is indicated by the perceived extent to which the database requires
new knowledge from the healthcare promoters as well as the perceived quality of the existing
knowledge that the healthcare promoters possess. In line with suggestions by Wejnert (2002), both
indicators are intended to measure the extent to which the existing knowledge base of the health
practitioners differs from the required knowledge base for using the prevention database of RIVM.
Thereby, the perceived newness of the database can be investigated. The second dimension, the level
of perceived intellectual difficulty associated with using the database, refers to how difficult it is for
the health practitioners to overcome the knowledge gap (Rogers, 2010). Hence, it is indicated by the
perceived degree to which the functions of the database are self-explanatory and the perceived
availability of support by the RIVM for healthcare promoters to learn how to use the database
(Fitzgerald et al., 2002).
The independent variable “trialability” has one dimension. The perceived degree to which an
innovation may be experimented with on a limited basis is measured based on four indicators. Here, it
is important that opportunities exist for healthcare promoters to experiment with the database (Rogers,
2010). Therefore, the first two indicators ask about the perceived opportunities to experiment with the
database and more specifically about the perceived amount of prototypes available for
experimentation. Moreover, it is crucial that it is actually feasible for the healthcare professionals to
experiment with the available opportunities (Rogers, 2010). Hence, the next two indicators investigate
the perceived difficulty of trying the database and the extent to which the healthcare promoters receive
guidance during the experiment.
The independent variable “observability” has one dimension. The perceived degree to which
the results of the database are visible to potential adopters through other users that communicate about
its benefits is measured based on two indicators. On the one hand, the results of the database are more
visible to the municipality as a potential adopter if there exist more health promoters that already use
the innovation and communicate about its benefits (Rogers, 2010). These users can become visible to
the municipality, for example, by means of peer practices or meetings. Therefore, the first indicator
asks about the existence of other health care promoters that use the database and communicate about
its benefits. On the other hand, the visibility of the results of the database is also determined by the
extent to which the opinions of these users can influence the decisions of the municipality (Rogers,
2010). Thus, the second indicator measures the perceived influence from opinions of those health care
promoters that use the database.
Finally, the independent variable “communication channels” has two dimensions. The first
dimension, the level of implementation of the communication channels, refers to the existing
communication network. As outlined in the theory section, three network factors are important
indicators of this dimension. These are the amount of available communication channels (Abraham &
Rosenkopf, 1997), the strength of the relations between the RIVM and the healthcare promoters
(Valente, 1995; Ahuja, 2000), and the degree of homophily (McPherson et al., 2001). The second
dimension, the level of utilization of communication channels by the RIVM, refers to how well the
RIVM is acting as a disseminator of information about the database. In line with the theory section,
three indicators can be identified that measure the quality of communication by the RIVM. These refer
to the breadth of use of the communication channels by the RIVM (Abraham & Rosenkopf, 1997), the
efforts spent on promotion by the RIVM (Rogers, 2010) and the fit of the database marketing strategy
to the targeted audience of healthcare promoters (Rothwell & Wissema, 1986).

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3.5 Data analysis
Since our data is qualitative, we choose a qualitative content analysis method (Berg et al., 2004; Flick,
2009) to analyse the collected data. Each interview is first transcribed and subsequently coded using
NVivo. To ensure data accuracy, the same data is coded by two of us separately, while the third one is
auditing the process and results of the data coding (Lincoln & Guba, 1985). The first round of coding
is open coding. Here, the interview data is screened for recurring phenomena and broken down into
concepts. In the following, axial coding is used to link the identified concepts into categories. Lastly,
selective coding is used in order to develop core categories that can be matched with the theoretical
concepts derived from our independent variables (Flick, 2009). This coding process basically has two
important outcomes. First, the coding process highlights the factors that the respondents perceive as
important and second, it provides several in-depth qualitative insights for the reasons of this
importance. Based on this, we subsequently score the relative importance of each independent variable
with a plus (important), zero (unclear) or a minus (not important) and the reasons for this tendency are
noted accordingly. This score and the identification of relevant reasons and factors is based on
thorough evaluations during the coding process described above. This procedure is repeated for each
municipality separately.
In the next step, this data is used to evaluate the hypotheses contained in the conceptual
model. In this study, a hypothesis is supported if the importance of the independent variable for the
adoption of the intervention database is recognised by two thirds or more of our interviewees, i.e.
when 6 or more out of the 9 interviewees indicate a positive relative importance (plus) of a particular
independent variable. Otherwise, a hypothesis is not supported. This information is complemented by
qualitative insights that stem from the coding process, for example to highlight the main reasons for
the importance or lack of importance of a particular independent variable. Furthermore, the importance
of the indicators is also derived. An indicator is considered to be important for a specific independent
variable, if two thirds or more of the interviewees indicate a positive relative importance (plus) for this
indicator. For each independent variable, we thus obtain its relative importance for all municipalities
as well as important reasons and relevant indicators. Thereby, we not only find support for hypotheses,
but also provide fine-grained details about each independent variable. Furthermore, new factors that
emerge as new themes from the coding are discussed. Thereby, we can add new factors to our
theoretical model that are relevant for the adoption of the database.

3.6 Research quality indicators

According to Bryman (2012, p. 390), there are four research quality indicators for qualitative research.
Several measures are undertaken in order to increase these.
Within the scope of this study, three researchers work together on conducting and analysing
the interviews. By means of multiple discussions and several coding rounds, it is ensured that the three
researchers can come to a collective agreement about the interpretations of the results (LeCompte &
Goetz, 1982). Therefore, the study’s internal reliability is rather high. However, it is difficult to
replicate the results of our study, because our study is qualitative in nature. In particular, the coding
and data analysis of the open questions are subjective. This hampers the external reliability of our
research. To remedy this problem, we transcribe the interviews and collect and present information
about our interviewees so that the replicability of our study can be increased. The general interview
guide can be found in Appendix B. In addition, our underlying theoretical reasoning, and methods of
data collection and analysis are clearly explained. Also, triangulation is applied by involving multiple
observers (Denzin, 1970), as each interview is coded by three researchers. By doing so, the subjective
perception of each individual coder is minimized. However, as the interviews are conducted at one
moment in time, future interviewees may still have deviating replies since their opinions might change

11
(LeCompte & Goetz, 1982). Thus, some weaknesses regarding the external reliability of our study
cannot be solved.
Moreover, this study makes use of snowball and convenience sampling to select relevant cases
and interviewees. Since we do not use a random sampling strategy, the generalizability of the research
is decreased (LeCompte & Goetz, 1982). Furthermore, the very specific case of the intervention
database by the RIVM can not be generalised to other databases by other organisations. In addition, as
outlined in 3.3, we also cannot control for non-response biases. Hence, the external validity of this
study is low. Since this is due to our multiple-case study design, this is inevitable. Finally, two
measures were undertaken to achieve a high internal validity. First, our interview questions are
phrased such that we can gain insight into the empirical understanding by the participant. Thereby, we
are able to identify credible causal relationships based on the participant’s understanding. Second, an
extensive literature research is done to ensure that the correct indicators are derived. Both measures
ensure that our observations match the ideas developed in the theory section (LeCompte & Goetz,
1982).

4. Results
4.1 Characteristics of participating municipalities
The nine included municipalities are located across the different provinces in the Netherlands. In
particular, five municipalities are located in Gelderland, two in Utrecht, two in Zuid-Holland and one
in Noord-Brabant. Some of the participating municipalities are rather small, while others are
comparatively large. Regarding the interviewees, five of the interviewees are female and four are
male. The age of the respondents ranges between 25 and 67 years. Among these interviewees, six
people do not know of the database and do not use it, two people know and do use the database and
one person knows the database but has never used it.

4.2 Key Findings

The table showing the scores of the perceived importance of the independent variables and the
corresponding indicators can be found in Appendix C. In the following, we discuss the importance of
each independent variable using qualitative insights.

4.2.1 Relative Advantage

The importance of the relative advantage is recognised by all nine respondents. One illustration can be
given by the example of respondent 4 (R4). She has heard about the database, but never used it before.
However, she claims to “have used another database from the Youth Institute, called Movisie”. After
some follow-up questions, it becomes clear that the relative advantage is a major reason for why she
does not use the database by the RIVM, but instead uses the database developed by the Youth
Institute: “the database by the RIVM should have added value, why else would I use it?”. All other
respondents confirmed that the relative advantage of the RIVM database is important in determining
their willingness to adopt it. One recurrent explanation provided by the respondents was the reference
to obvious reasons: They consistently claim that it should be clear that they only use a database if it is
better. For example, R3, who did not know the RIVM database beforehand, says: “If there are other
and better databases, why should I then use the one from the RIVM?”
The features that the RIVM database is not performing better than other prevention techniques
mostly refer to the kind of information it provides. For example, R2, who did use the RIVM database
before, states: “the information provided [in the RIVM database] is often quite general. [...]. [In the
RIVM database there] are all kinds of beautiful sentences, but nothing that is practical or specific.”

12
Furthermore, R6, who did not know about the RIVM database, believes that the information provided
in the database should also help him to monitor the success of the suggested interventions: “I want to
be supported in how you could measure it, so not only how to implement but also how do you evaluate,
because this is really hard”. The latter clearly refers to our indicator “contribution to prevention in
health care”. As seven of the respondents indicate the importance of this indicator, it should be a
specifically relevant indicator for the relative advantage of the database. Furthermore, from the coding,
it becomes clear that a “higher efficiency” is also an important indicator for the relative advantage of
the RIVM database, as six respondents mention its relevance (see Appendix C). However, not all
aspects of the RIVM database are important barriers for its relative advantage. With regards to the
relative advantage of the RIVM database, the respondents usually praise the broad scope of the
information provided in it. For example, R2 highlights that the database provides a lot of information,
which is useful for his municipality since it does not have the capacity itself to research this
information: “The [RIVM] database is important, especially for smaller municipalities who do not
have as much people working on policies. There is lots of information.”
In sum, it can be seen that the relative advantage is of high importance - for municipalities that
do not know the RIVM database, for those that use it as well as for those that do not use it. As shown
above, different reasons for this importance refer to the existence of other databases, mere obviousness
as well as the kind of information provided in the database. The biggest aspects that the database needs
to be improved at are that it needs to contain more practical information as well as support for
monitoring the success of the interventions. The respondents uniformly indicate that there is a positive
causal relationship between the relative advantage of the RIVM database and their willingness to
adopt it. Hence, hypothesis one is supported although the RIVM database scores relatively low on
relative advantage.

4.2.2 Compatibility
The compatibility of the RIVM database with existing values and practices is recognised to be
important by all nine respondents. Basically, two reasons are mentioned for why the RIVM database
should be compatible with existing values and practices. First, one prevalent value among the
respondents is the objectivity of the data they are provided with. For example, R2 says that “a lot of
other preventive measures, like for example stopping with smoking, are supported by interest groups
and you want someone who has no interest”. In other words, for the municipalities, it is important that
the information they receive within a database should be impartial and not influenced by certain
groups. This norm should be complied with by the RIVM. Second, several respondents highlight that
the RIVM database should be adjustable to the specific practices at the municipality. As R3 argues:
“[The RIVM database] should fit to the scale of the municipality, for example interventions that work
in one municipality do not automatically work in our municipality. It should fit with what the
municipalities are doing”. In other words, the practices of the municipalities are rather specific and
require that the RIVM database is suitable for these practices. Therefore, according to R5, the
compatibility of the RIVM database needs to be improved by integrating it into the usual practices of
the local authorities: “I think the RIVM has to couple [their information] to what is usually used by
policy makers. For example, all policy makers have to keep track of legislative changes for which they
use the VNG. If you integrate [the RIVM database] in there or add a link, I think everyone will find
that handy”. If this is not taken into account, compatibility is indeed seen as a crucial factor that
influences the adoption decisions by the municipalities. For example, R7 says that she “would not use
the [RIVM] database if the scientific research is not translated into practical solutions”.
As can be seen, compatibility is recognised as important across all municipalities. Main
reasons for this are the required conformity with norms that require the data to stem from objective
sources, and the requirement for the database to be tailored towards the specific practices of the local

13
authorities. In general, compatibility is acknowledged as a major factor that positively influences the
willingness of local authorities to adopt the database by all municipalities. With regards to the RIVM
database, the respondents argue that it could be improved by adjusting it to the different practices of
the municipalities. Therefore, hypothesis two is supported while the RIVM database scores rather low
on compatibility.

4.2.3 Complexity
From the interviews it becomes clear that all nine interviewees acknowledge complexity as an
important factor. All interviewees state that if the RIVM database is not easy to use, this will influence
their willingness to adopt it. For example, R7 says: “The [RIVM] database should be easy to
understand, otherwise I will not use it as much”. This refers to the importance of the indicator “self-
explanatory functions”, which is recognised to be an important indicator by a total of six respondents
(Appendix C). There are two reasons for that complexity is such an important factor. The first reason
that is consistently reported by the respondents is their lack of time. For example, according to R3,
“the information in the [RIVM] database should be easy, quick and short, especially if you see how
little time we have. Therefore, it should be easy to understand and quick to use”. Moreover, R5 also
argues that time is important with saying: “It is important for me that it saves time”. From this it
becomes clear that it is due to their limited time that the municipalities require the RIVM database to
be quick and easy to use. The second reason provided by the respondents refers to the possibility of
language gaps. For example, R4 argues that “especially the practical applicability in the sense of
language is important. There can be quite a gap between academic and everyday people [...] and it is
easier to use when the language is easier to understand”. So, the way the interventions are explained
should be less scientific so as to match the language of the local authorities.
In sum, all respondents have acknowledged that complexity is important. The main reasons for
why they see complexity as important is due to the limited time they have and perceived language
gaps between themselves and academia. As can be seen, there is a negative causal relationship
between the complexity of the RIVM database and the willingness of the municipalities to adopt it.
Therefore, hypothesis 3 is supported.
However, it is worth noting that those respondents who use the RIVM database say that using
it is not complex. For example, R2, who uses the RIVM database, finds it relatively easy to use,
because the “information in the [RIVM] database is easy to find, the text reads nicely, and the
information is bundled together and the database includes lots of practical examples”. And further:
“The information in the [RIVM] database is clear. [...] The advantage of this is you do not have to
translate from what is said towards how you are going to do it.” In other words, even though
complexity is recognised by all municipalities as an important factor, it is not a weakness of the RIVM
database as shown by the replies of the respondents who use it. Therefore, it is not important for the
RIVM to reduce the complexity of its database further.

4.2.4 Trialability
Eight of the nine respondents stated that they deem trialability not to be important. Basically, two
reasons are named by the municipalities for why they do not believe that testing or experimenting with
the RIVM database is important. First, the respondents state that they do not view testing the database
as important because of their limited time. For example, R7 says: “If I can test the [RIVM] database,
this would take me time and I do not want to give priority to this”. Similarly, R3 says “I only have so
much time, so no that is not important to me”. The second major reason they give is that they believe
in their own capacities. They do not feel that testing is necessary because they are able to find what
they need on their own. For example, R2 says: “I’m not interested in experimenting, I expect the
[RIVM] database to work and I will try to find the information I need on my own”. Also, R5 says: “I

14
don’t find testing and experimenting important, if a new version of the database becomes available I
can find it out on my own, I do not need support for that”. In addition, the one respondent (R8) who
finds trialability potentially important does this only under several conditions: “I would test the
[RIVM] database but only if it has benefits for me too, for example in that I become more
knowledgeable. If I’m convinced of its worth and used it in the past, I would cooperate [with testing].
But only testing because of the testing, no I would not do that”. What this shows is that people do not
want to experiment with the RIVM database if it is just for the sake of experimenting. Instead, they
want to be promised in advance certain benefits from the experiments. Since such benefits are not
apparent to them, they do not see any value in trying out the RIVM database.
In sum, all but one of the respondents state that they do not see the importance of trialability.
The main two reasons provided by the respondents are their limited amount of time, and the belief in
their own capacities to learn using the RIVM database, so that experiments become unnecessary. The
one person that sees the importance of trialability does this only under the specific condition that there
are some unknown benefits from testing. If these are not present, he also would not view trialability as
important. Based on these reasons, there appears to be a negative causal relationship between
trialability and the willingness of the local authorities to adopt the RIVM database. This is in contrast
to our hypothesis that there would be a positive causal relationship. Therefore, hypothesis 4 is not
supported.

4.2.5 Observability
Eight of the nine respondents consider observability to be important. Three different reasons are given
by the respondents for this. First, it is argued that experiences shared by other colleagues would
facilitate the learning and efficiency of the municipality, since colleagues can better articulate the
different features of the RIVM database. For example, R5 says: “It is important that other people
share their experiences with the [RIVM] database because you can learn from each other. They know
what we need to know. In that way, you can become more efficient as a municipality as a whole”.
Second, some municipalities point out that they appreciate the evidence of the functionality of the
RIVM database if its benefits are communicated by colleagues. For instance, according to R5, “it is
important that there are evidence-based interventions because then you know that those interventions
are working in other municipalities”. In other words, municipalities put emphasis on that the RIVM
database is already proven to be valuable by other local authorities. Third, a final reason for the
importance of observability is the trust in the colleagues and the information they provide. Several
respondents highlight this aspect. For example, R6 claims that “if a respected colleague of mine says
some technology or website is good, I trust their judgement, and will also look at it. But this works
also the other way around.” Apparently, the observability of the RIVM database plays an important
role in influencing the decision of local public authorities to adopt it. All the quotes above relate to the
indicator “Existence of other users that communicate about benefits of database” (Appendix C). This
is an important indicator for observability, as a total of 7 respondents recognised its importance.
Problematic in this regard is that the respondents consistently report that the observability of the
database is rather low. For example, R2, who does not find observability to be important, claims: “I’m
wondering whether colleagues know of the database because I barely hear them talking about it. It
wasn’t like colleagues told me about the database and told me there was a lot of useful information in
it.” This is also the reason why he does not think observability is important, as he adopted the RIVM
database without hearing from other colleagues: “To me it is not important that other people share
their experiences because I found it myself, I can’t exactly remember, maybe on a flyer or poster or
somewhere else”.
In sum, a large majority of the respondents report that the observability of the database does
have a big influence on their willingness to adopt it. Reasons for this are the trust in their colleagues,

15
the evidence stemming from their colleagues already using it and the improved learning and efficiency
from the advice by their colleagues. There is a positive causal relationship between the observability
of the database and the willingness of the authorities to adopt it. Therefore, hypothesis five is
supported, but the RIVM database scores rather low on observability.

4.2.6 Communication Channels

From the interviews it becomes clear that all respondents agree that communication channels are an
important aspect that influences their perception of the database. The main reason for this importance
given by the respondents is that they do not have sufficient information about the RIVM database. One
interesting illustration can be given for those respondents that did not have knowledge about the
RIVM database beforehand. After it was explained what the RIVM database is for and how it is used,
they consistently state that they would indeed be interested in using such a database. For example, R3,
who did not know about the RIVM database, states: “now that you have explained the [RIVM]
database, it sounds like something very helpful and can definitely be something interesting for our
municipality. [...] Since I never heard of the [RIVM] database, I would say they should put in more
effort in communicating about it”. From this it becomes clear that the lacking communication from the
RIVM was the major cause for why six out of the nine interviewed municipalities did not adopt it. If
they would have heard about the RIVM database, their perception of it and their willingness to adopt it
would have increased. Interestingly, even the respondents that have knowledge of the database
consistently report that the communication by the RIVM about their database is lacking. For example,
R5 who has adopted the RIVM database states: “I’m happy with the [RIVM] database, I’m glad it’s
even there. I however doubt if the database is often used because of [...] the communication about it”.
Moreover, R4, who has not adopted the database but knows about it, states “I think they should put
more effort in to communicate about the database, I never received any information from them about
the database”. So, even the people who somehow found out about the database believe that there is not
enough communication about the database. Instead, they found the database by accident. For example,
R4 says: “I think I found out about the [RIVM] database when I was at a networking event, and some
people from the RIVM were there as well and they pointed me to the database”. Furthermore, R5 says:
“I was looking for information, like what the RIVM database contains, and then by accident found it”.
In the quotes above, the indicator “Effort spent on promotion” is mentioned several times. This
indicator is recognised by a total of 6 respondents (Appendix C). Therefore, this appears to be an
important indicator for communication channels.
A second reason for why communication channels are perceived to be important is that the
municipalities do receive most information about healthcare via other organisations than the RIVM,
such as the association of Dutch municipalities (VNG) and the municipal health office (GGD). The
common sentiment of the respondents is that the VNG and GGD have available communication
channels that effectively approach them. For example, R6 states: “I’m quite dependent on the VNG
and their opinion is really important to us”. The VNG is an overarching organization which offers a
platform for opinion formation and innovation within municipalities (VNG, 2016). Several
respondents suggest that the RIVM could utilise the communication channels provided by the VNG.
For example, according to R2, “there never was information about the RIVM database in the digital
weekly newsletters by the VNG. [...] The RIVM needs to be more active in newsletters, messages on
LinkedIn or Twitter, there are different channels. The VNG sends a newsletter every week which
includes the topic of health. Add to that, place a message there, there you will reach a lot at least on
the level of municipalities.” Furthermore, the GGD is also mentioned multiple times as an important
source of information regarding healthcare and prevention. The GGD is active in multiple regions
across the Netherlands and is an organization which is responsible for the protection, monitoring and
promotion of health within those regions (GGDRU, 2016). For example, R8 states “I’m in direct

16
contact with the GGD, via the health broker, that is an important source of information. If we are
talking about prevention in healthcare, the GGD is the one [I go to]”. This implies that the VNG and
GGD both form important information sources for municipalities that the RIVM so far failed to
involve when communicating about the database.
In sum, communication channels are recognised by all respondents as important aspects
influencing their awareness of the database. The main reasons for this are the lack of information
received, as well as the fact that there are several available communication channels that effectively
approach them. The respondents consistently report that the RIVM does not utilise these channels
well, which is why their perception of the features of the database is hampered. Therefore, there is a
positive causal relationship between the utilisation of communication channels and the awareness of
the features of the database. Hence, hypothesis six is supported, but the RIVM does not communicate
well about the database and fails to utilise existing communication channels.

4.2.7 Social involvement

From the interviews, one recurring theme could be identified that is an additional important factor that
can influence the willingness of municipalities to adopt the database. We refer to the important theme
that is consistently mentioned by the respondents as “social involvement”. The respondents describe
that the best results in prevention in healthcare can be achieved when society is involved in the process
of prevention building. Therefore, the respondents stress that the interventions need to actually match
the needs of the general public, and this can only be achieved if they are developed in collaboration
with different relevant social groups. For example, R4 states: “The welfare commission is nowadays in
direct contact with the citizens. You know, we need to match it with their needs.” Similarly, R3 says:
“more and more tasks need to be executed in collaboration with the social domain”. From this it
becomes clear that one important social group that needs to be involved is the general public. Another
social group mentioned are other health organisations. That is, not only collaboration with the general
public is important, but also collaboration with other organizations is perceived to be essential. For
example, R6 says: “I think collaboration with the GGD is really important, since they execute most
interventions [...] and know best about how it fits the public”.
In sum, it is important for the local authorities that the information provided in the database
matches the needs of the general public. Therefore, local authorities are more prone to adopt the
database if the information provided in it, especially its interventions, are developed in collaboration
with the general public and other health organisations that are in direct contact with the general public.

5. Discussion
5.1 Theoretical implications
Our results show that our conceptual model from the theory section is largely correct. Five of the six
proposed hypotheses for the adoption of the RIVM database among municipalities are supported.
However, there are two issues with regards to the chosen conceptual model.
The first issue is that hypothesis 4 is rejected. In contrast to Rogers (2010), there is no positive
causal relationship between trialability and the willingness of local authorities to adopt the database.
Therefore, the adoption factor “trialability” is not applicable to the adoption of the RIVM database
among municipalities. The reason for this contradictory result may be theoretical. As outlined in our
result section, the main reasons of why trialability is not important are the lack of time the authorities
have and the belief that trying out the database is not necessary. Rogers (2010) assumes in his theory
that potential adopters would generally be interested in trying out the database. However, our study
reveals that this is not the case if the adopters are busy with other things and have a strong belief in

17
their own capacities. This adds to existing literature by showing that adopters with certain features
(like in our case the local authorities) do not value trialability as an important factor. Future research
should investigate whether this observation also holds for other cases in the healthcare sector.
The second issue refers to “social involvement”. Our results indicate that social involvement is
an additional factor of importance. When implementing interventions, the municipalities have noticed
that it is important to consider the needs of the citizens to improve healthy living, which is why they
deem social involvement important. There are two possibilities for how this factor may influence the
willingness to adopt. On the one hand, social involvement may have an effect on the adoption factors
and thereby indirectly influence the willingness to adopt. For example, through social involvement,
interventions could be developed that are easily accepted by the general public, since those better
match their needs. Therefore, one could argue that the increased match with user needs enhances the
practicability of the developed interventions, as these can be better implemented within municipalities.
This would enhance the compatibility with existing practices of the municipalities and thereby
influence the adoption factor “compatibility”. Furthermore, due to this increased practicability and
acceptance by the public, the municipalities would face less costs and time to implement the
intervention. This would result in a higher efficiency of implementing the interventions within
municipalities, which is an important aspect of the adoption factor “relative advantage”. In other
words, social involvement could have an effect on the “compatibility” and “relative advantage” of the
database and thus indirectly influence the willingness to adopt. On the other hand, social involvement
may also directly influence the willingness to adopt. For example, the database could be known for
being developed in collaboration with the general public, and for this reason solely, the municipalities
would be more willing to adopt the database. In this case, social involvement could directly influence
the willingness of municipalities to adopt the RIVM database and it therefore would be a separate
adoption factor. However, it is still unclear which effect of social involvement is prevailing, and how
precisely social involvement influences the willingness to adopt. Therefore, future research should
gain a better understanding of the role of social involvement in adoption theory.
The discussion above shows that our conceptual model based on Rogers’ (2010) adoption
theory is correct with the exception of the variable “trialability”, but neglects “social involvement”,
which is one important variable that also explains the adoption of the RIVM database. This matches
common criticisms of adoption theory in the literature. Those critics argue that, if users are left only
with the choice whether or not to adopt something that someone else developed, there may be a
mismatch with the needs the users actually have (Hienerth, 2006; Essén & Östlund, 2011). Therefore,
users should be involved in the process so that they can actively articulate their needs (Von Hippel,
1976, 1988; Baldwin et al., 2006) and thereby construct their own ideas (Pinch & Bijker, 1984). It
appears that sociological theories (Pinch & Bijker, 1984) and user-producer interaction theory (Von
Hippel, 1988) may provide a better understanding of the adoption behaviour in the healthcare sector,
such as in our case. More research is needed to understand in which situations these theories would
add to conventional adoption theories to explain the behaviour of potential adopters.
In addition, our research has three further theoretical implications. First, our study gives a
more nuanced understanding of the adoption factor “complexity”. While the common literature usually
refers to the lack of knowledge as the main reason for why complexity is to be avoided (Wejnert,
2002), in our study, the main reasons for this refer to the lack of time the adopters have. Therefore,
some adopters may very well possess the knowledge required for understanding a possibly complex
database, but they find it more important that it is easy to understand because they have little time.
Therefore, “time efficiency” might be a relevant indicator for complexity. Future research should
investigate whether this is a suitable indicator in other situations.
Second, our study provides a more fine-grained understanding of the adoption factor
“observability”. According to the local authorities, observability is basically important because they

18
would trust the advice by their colleagues more, because they appreciate the evidence provided by the
colleagues and also because they believe their colleagues would be able to better explain the
functionality of the database. Trust and evidence are already known in existing literature to be
important reasons for the importance of observability (Rogers, 2010). However, the fact that
colleagues also better know the needs of the potential adopters and thereby can better explain the
function of an innovation is a new aspect that adds to existing literature of adoption theory (Lee,
2004). Therefore, the “ability of colleagues to explain the innovation” might be a relevant indicator for
observability. Future research should investigate whether this is a suitable indicator for other cases.
Third, our study also has theoretical implications with regards to the independent variable
“communication channels”. We show that the most important indicators for the importance of
communication channels refer to their utilisation, but not to the network. For example, “utilisation”
indicators such as a “broader use of channels” (Abraham & Rosenkopf, 1997) are seen as important. In
contrast, “network” indicators such as “homophily” (McPherson et al., 2001) are found to be rather
irrelevant. This might be because in our case, the network is already well implemented, and the RIVM
merely fails to make use of it. Existing but not utilised communication opportunities are, for example,
the VNG and GGD. This shows that the theory of communication networks (Rogers & Kincaid, 1981)
is rather insufficient to explain the willingness of the municipalities to adopt the database. It appears
that an actor-centered approach (Latour, 2005) that explicitly focuses on the utilisation of the existing
communication opportunities is more suitable in our case. Future research could investigate in which
situations such an approach contributes to a better understanding of the reasons for adoption.

5.2 Managerial implications

Since the goal of our study is to provide advice to the RIVM of how to improve the adoption of their
database, this research has also several implications for the RIVM. In light of the results, the relative
advantage needs to be improved by enhancing the content of the database. More specifically, it is
required that the provided information becomes more practical and the database better supports the
monitoring of the success of the interventions. The RIVM should also make sure that the database is
compatible with the current practices of the municipalities. For example, the database can be
connected to the online website and newsletters by the VNG that most municipalities already use. The
information provided in the database should also be objective. While complexity is recognised as an
important factor, the database is not complex and the RIVM does not have to focus on making it easier
to understand. Also, improving the opportunities to experiment with the database is not necessary,
since trialability is not seen as an important adoption factor. Improving observability, however,
appears to be necessary, since it is mentioned by many interviewees. This can be done, for example,
by organising social network events. Furthermore, the communication by the RIVM is a crucial aspect
that needs to be improved. Several communication channels are available for use, among which the
newsletters by the VNG and the GGD are the most important ones. Finally, the RIVM should ensure
that the interventions in the database are generated based on social involvement, e.g. by approaching
the local health organisations that are in direct contact with the general public.

5.3 Limitations
This research has some noteworthy limitations. First, triangulation of the data sources has not been
possible. When this study set out, the idea was to interview three local authorities that adopted the
database, three that know about the database but did not adopt it and three that do not have knowledge
about the database. This was not possible, since there were not enough potential interviewees that
knew about the database. Therefore, we interviewed only two local authorities that adopted the
database, and only one that knew of it but has not adopted it. This is a crucial limitation of the quality

19
of our research, since it undermines the internal validity. Furthermore, only the local authorities at the
municipalities have been interviewed. However, the general practitioners within municipalities as well
as the GGD are also potential adopters of the database and could provide additional valuable insights.
Therefore, future research should secure triangulation of the data sources, for example by taking into
account a larger sample of interviewees and also interviewing general practitioners and other
healthcare related organisations.
Second, there are limitations with regards to research design and sampling strategy. Since we
employ convenience and snowball sampling, our research cannot be generalised to a larger population
(Bryman, 2012). Furthermore, since we use a multiple-case study design, our results are case-specific.
Both aspects hamper the external validity of our study. Nevertheless, because there is a limited number
of municipalities in the Netherlands, nine case studies as in our study are still informative to give some
insights into the adoption behaviour by different health promoters. In particular, our study provides in-
depth insights into the causal relations of the identified adoption factors.

6. Conclusion
This research aimed at answering the research question: “What factors influence the willingness of
health promoters to adopt the intervention database as developed by RIVM and in turn help the RIVM
improve the adoption of this database?” Nine different municipalities were asked in comprehensive
semi-structured interviews. The most important influential factors that were identified in this study are
the social involvement of the general public for developing the interventions that make up the
database, the communication about it, and its relative advantage, compatibility, complexity and
observability. As shown in the managerial implications, worthy to improve are the communication of
the RIVM, its social involvement, the relative advantage of the database with regards to the
information provided in the database as well as its compatibility with existing practices. Thus, the
most important contribution of this research is that it showed that the RIVM can improve the
willingness of local authorities to adopt the database principally by improving the aspects mentioned
above.

20
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 Appendix A. Operationalization table
Concept Dimensions Indicators Measurement

1. Willing- 1.1 Level of 1.1.1 Potential willingness to adopt 3bi. Would you open to promote or use the database in the
ness to adopt Willingness to adopt the intervention database of the future? Also question 3b.
RIVM

2. Relative 2.1 Level of 2.1.1 Expected cost reduction 5bi. How important is it in your opinion that the database
Advantage perceived economic through adoption of database makes it cheaper to promote healthy living? Also,
advantages questions 4, 5a and 11.

2.1.2 Expected efficiency of 5bii. How important is it for you that the database enables
database you to more efficiently promote healthy living? Also,
questions 4, 5a and 11.

2.2 Level of 2.2.1 Perceived friendliness of 5biii. How important is it for you that the database is more
perceived usefulness database to the municipality user-friendly than traditional ways of promoting healthy
living? Also, questions 4, 5a and 11.

2.2.2 Expected contribution of 5biv. How important is it for you that the database
database to health intervention additionally contributes to prevention in health care?
Also, questions 4, 5a and 11.

2.3 Level of 2.3.1 Perceived contribution to 5bv. How important is it for you that using the database
perceived social image of municipalities through improves your image in relation to your own health care
advantages expected appreciation by patients related activities? (through the appreciation of the
for advice based on database citizens) Also, questions 4, 5a and 11.

3. Compa- 3.1 Level of 3.1.1 Expected extent to which 6bi. How important is it for you that for using the
tibility perceived health care promoters need to database, you do not need to adjust your current practices
compatibility with make adjustments of their and skills of being a health promoter? Also, questions 4,
6a and 11.
existing practices practices and skills
and skills of the
potential adopters 3.1.2 Extent to which changes of 6bii. How important is it for you that the database fits
existing skills and practices are with your day-to-day practices? Also, questions 4, 6a and
difficult to implement 11.

3.2 Level of 3.2.1 Perceived fit of database with 6biii. In your opinion, how important is it that the
perceived existing healthcare morals and database fits with the existing values and norms in
compatibility with norms healthcare? Also, questions 4, 6a and 11.
existing values and
norms of potential
adopters

4. Com- 4.1 Level of 4.1.1 Perceived extent to which 7bi. How important is it in your opinion that health
plexity perceived newness database requires new knowledge promoters are able to fully make use of the database
of database from health promoters functionality with their current knowledge? Also,
questions 4, 7a and 11.

4.1.2 Perceived quality of existing 7bii. From your perception, how important is it for using
knowledge of healthcare promoters the database that the knowledge of health promoters about
the use of databases is strong? Also, questions 4, 7a and
11.

4.2. Level of 4.2.1 Perceived degree to which 7biii. How important is it for you that the database’s
perceived the functions of the database are functionalities are self-explanatory and easy to
intellectual self-explanatory understand? Also, questions 4, 7a and 11.

25
 difficulty associated 4.2.2 Perceived availability of 7biv. How important is it for you that there is enough
with database support by the RIVM for support by the RIVM to understand how to use of the
healthcare promoters to learn the database? Also, questions 4, 7a and 11.
use of database

5. Trial- 5.1 Perceived 5.1.1 Perceived opportunities to 8bi. How important is it in your opinion that there are
ability degree to which an experiment with database enough opportunities to test the database? Also, questions
innovation may be 4, 8a and 11.
experimented with
on a limited basis 5.1.2 Perceived amount of 8bii. How important is it in your opinion that you could
prototypes available for test so-called beta versions of the database? Also,
experimentation questions 4, 8a and 11.

5.1.3 Perceived difficulty of trying 8biii. How important is it to you that trying out the
database database is not difficult? Also, questions 4, 8a and 11.

5.1.4 Extent to which health 8biv. How important is it in your opinion that health
promoters receive guidance during promoters are appropriately guided in testing the
the experiment database? (by the RIVM?) Also, questions 4, 8a and 11.

6. Obser- 6.1 Perceived 6.1.1 Existence of other health care 9bi. How important is it to you to be able to learn about
vability degree to which the promoters that use the database the benefits of the database through other healthcare
results of the and communicate about its promoters that already use the database? Also, questions
4, 9a and 11.
database are visible benefits
to potential adopters
through other users 6.1.2 Perceived influence from 9bii. How important is it for you that their opinions are
that communicate opinions of those health care credible enough to influence your decision to use the
about its benefits promoters that use the database database? Also, questions 4, 9a and 11.

7. 7.1 Level of 7.1.1 Amount of available 10bi. How do you receive information from the RIVM
Communi- implementation of communication channels and other healthcare-related organisations? Which
cation communication channels? Also, questions 4, 10a,b and 11.
channels (Network)
Channels
7.1.2 Strength of relations between 10bii. How important is it for you that you have strong
RIVM and healthcare promoters relations with the RIVM? Also, questions 4, 10a,b and 11.

7.1.3 Degree of homophily 10biii. How important is it for you that the values and
norms of the RIVM and your municipality are similar?
Also, questions 4, 10a,b and 11.

7.2. Level of 7.2.1 Breadth of use of the 10biv. How important is it for you that you receive
utilization of communication channels by RIVM information about the database through a variety of
communication different communication channels about the database?
channels by RIVM
Also, questions 4, 10a,b and 11.

7.2.2 Effort spent on promotion by 10bv. How important is it for you that the RIVM puts in a
RIVM lot of effort to inform people about their database? Also,
questions 4, 10a,b and 11.

7.2.3 Fit of database marketing 10bvi. How important is it for you that the RIVM is
strategy to targeted audience of convincing when advertising its database? Also, questions
healthcare promoters. 4, 10a,b and 11.

26
Appendix B. Interview questions
Interview questions that are asked to local public authorities of municipalities.

I. Before start of interview

-We would like to record this interview so that we can use it for reference while proceeding with this study. Do you give
permission for your interview to be recorded?

II. Content of interview

1. Factsheet information
a. What is your name and surname? (also note gender)
b. How old are you?
c. How long have you been working at the municipality?
2. General questions (Ice-breaking)
a. Could you describe your current job?
b. What do you think about prevention in healthcare?
c. Is prevention in healthcare an important issue in your municipality?
d. How do you think prevention can be most successful?
3. Willingness to adopt
a. Have you heard about the intervention database that the RIVM has developed? Do you know what it is
for?

If the interviewee does not know the intervention database, go to section 10c.
Continue with question b. if the interviewee knows the intervention database

b. Have you ever used or promoted the database? Why/Why not?

i. If no: Would you be open to promote or use the database in the future? Why/ Why not?

4. Open questions about the perception of database

a. Do you see the database as potentially helpful for prevention in healthcare? Why/Why not?
b. What factors would you say are important strengths of the database? Why?
c. What factors would you say are important weaknesses of the database? Why?

5. Perceived Relative advantage

a. Would you say it is important for this database to be better than existing preventative measures?
Why/why not?
i. If yes: How do you feel about the database in comparison to other measures for prevention in
health care? In comparison to other technologies, what are strengths of the database and what
are its weaknesses? How could this be improved?
b. Checklist, only asked if relative advantage is important.
i. How important is it in your opinion that the database makes it cheaper to promote healthy
living? Follow-up: Why? Do you have an example? To what extent does the database make this
promotion cheaper? How could it be improved?
ii. How important is it for you that the database enables you to more efficiently promote healthy
living? Follow-up: Why? Do you have an example? In your opinion, to what extent does the
database increase efficiency? How could it be improved?
iii. How important is it for you that the database is more user-friendly than traditional ways of
promoting healthy living? Follow-up: Why? Do you have an example? Is the database more
user-friendly than traditional ways of promoting healthy living? How could it be improved?
iv. How important is it for you that the database additionally contributes to prevention in health
care? Follow-up: Why? Do you have an example? To what extent does the database, in your
opinion, additionally contribute to prevention in health care? How could it be improved?
v. How important is it for you that using the database improves your image in relation to your
own health care related activities? (through the appreciation of the citizens) Follow-up: Why?
Do you have an example? In your opinion, to what extent does advice based on the database
improve the image of healthcare promoters? How could it be improved?

6. Perceived Compatibility
a. Do you think that it is important that the database fits with your day-to-day practices and existing values
at the municipality? Why/why not?
i. If yes: In your opinion, how compatible is the database with your everyday work and existing
values? How could this be improved?
b. Checklist, only asked if compatibility is important.

27
 i. How important is it for you that for using the database, you do not need to adjust your current
practices and skills of being a health promoter? Follow-up: Why? Do you have an example? To
what extent would you say that for using the database, health promoters would need/needed to
adjust their current practices and skills? How could it be improved?
ii. How important is it for you that the database fits with your day-to-day practices? Follow-up:
Why? Do you have an example? To what extent does the database, in your opinion, fit with
your day-to-day practices? How could it be improved?
iii. In your opinion, how important is it that the database fits with the existing values and norms in
healthcare? Follow-up: Why? Do you have an example? To what extent does the database, in
your opinion, fit with the existing values and norms in healthcare? How could it be improved?

7. Perceived Complexity
a. Would you say that it is important that the database is easy to use and understand? Why?
i. If yes: In your opinion, how complex is the database to use and understand? What makes the
database easy to use and understand, and what makes it difficult to use and understand? How
could this be improved?
b. Checklist, only asked if complexity is a problem.
i. How important is it in your opinion that health promoters are able to fully make use of the
database functionality with their current knowledge? Follow-up: Why? Do you have an
example? To what extent does the database, in your opinion, enable health promoters to fully
make use of the database functionality with their current knowledge? How could it be
improved?
ii. From your perception, how important is it for using the database that the knowledge of health
promoters about the use of databases is strong? Follow-up: Why? Do you have an example?
How strong is the knowledge of health promoters about the use of the database, in your
opinion? How could it be improved?
iii. How important is it for you that the database’s functionalities are self-explanatory and easy to
understand? Follow-up: Why? Do you have an example? To what extent are the database’s
functionality self-explanatory and easy to understand for you? How could it be improved?
iv. How important is it for you that there is enough support by the RIVM to understand how to use
of the database? Follow-up: Why? Do you have an example? To what extent is there enough
support by the RIVM to understand the use of the database? How could it be improved?

8. Perceived Trialability
a. Would you say it is important that you are able to test and experiment with the database? Why?
i. If yes: Were you, in your eyes, able to do this enough? What made it easy to try out the
database and what made it difficult? How could this be improved?
b. Checklist, only asked if trialability is important.
i. How important is it in your opinion that there are enough opportunities to test the database?
Follow-up: Why? Do you have an example? To what extent are there enough opportunities to
test the database? How could it be improved?
ii. How important is it in your opinion that you could test so-called beta versions of the database?
Follow-up: Why? Do you have an example? To what extent have you been able to use beta
versions to test the database? How could it be improved?
iii. How important is it to you that trying out the database is not difficult? Follow-up: Why? Do
you have an example? To what extent would you say that trying out the database is difficult?
How could it be improved?
iv. How important is it in your opinion that health promoters are appropriately guided in testing the
database? (by the RIVM?) Follow-up: Why? Do you have an example? To what extent would
you say is there an appropriate guidance for testing the database? How could it be improved?

9. Perceived Observability
a. Would you say it is important that other users share their experiences with the database? Why/why not?
i. If yes: How do other users share their experiences regarding the database? How could this be
improved?
b. Checklist, only asked if observability is important.
i. How important is it to you to be able to learn about the benefits of the database through other
healthcare promoters that already use the database? Follow-up: Why? Do you have an
example? To what extent have you heard about the benefits of the database through other
healthcare promoters? How could it be improved? Where do they discuss these benefits? (peer
practices/meetings)
ii. How important is it for you that their opinions are credible enough to influence your decision
to use the database? Follow-up: Why? Do you have an example? To what extent would you say
that their opinions can influence your choices to use the database? How could it be improved?

10. Perceived Communication Channels

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 a. How well were you informed about the database?
b. From whom did /do you receive information about the database?
i. If RIVM is not mentioned: Do you also receive information about the database by the RIVM?
ii. How could the RIVM improve its communication with you?
c. Checklist, always asked.
i. How do you receive information from the RIVM and other healthcare-related organisations?
Which channels? Is it important that there are many channels?
ii. How important is it for you that you have strong relations with the RIVM? Follow-up: Why?
Do you have an example? To what extent would you say that you have strong relations with the
RIVM? How could it be improved?
iii. How important is it for you that the values and norms of the RIVM and your municipality are
similar? Follow-up: Why? Do you have an example? How similar are these values and norms?
How could it be improved?
iv. How important is it for you that you receive information about the database through a variety of
different communication channels about the database? Follow-up: Why? Do you have an
example? To what extent would you say do you receive information through a variety of
different channels? How could it be improved?
v. How important is it for you that the RIVM puts in a lot of effort to inform people about their
database? Follow-up: Why? Do you have an example? To what extent would you say that the
RIVM puts in a lot of effort to inform the people about their database? How could it be
improved?
vi. How important is it for you that the RIVM is convincing when advertising its database?
Follow-up: Why? Do you have an example? To what extent would you say that the RIVM is
convincing when advertising its database? How could it be improved?

11. Only if the interviewee does not know the database

a. What would you see as a useful improvement for prevention in health care? What factors play a role and
what is important?
b. What kind of technology and what features of it would improve prevention in health care?
c. The RIVM has offered a prevention database for healthcare. The idea is that all relevant scientific
insights are gathered in a database, and that municipalities and different health professionals use the
newest insights from this database to provide advice to the general public.
i. Would you use such a database?
ii. What features would you like to see in such a database to use it?
iii. In our research, we have identified several aspects that might be important for such a database.
Can you characterise the extent that you perceive the following aspects to be important and
describe why?
1. Would you say it is important for such a database that it is better than existing
preventative measures? Follow-up: Why/why not? And what features are most
crucial for such a database to be better?
2. Do you think that it is important for such a database that it fits with the day-to-day
practices and existing values at the municipality? Follow-up: Why/why not? And
what features should the database have in order to be most compatible?
3. Would you say that it is important for such a database to be easy to use and
understand? Follow-up: Why? What aspects should be paid attention to in order to
make the database easy to use?
4. Would you say it is important for such a database to offer opportunities for testing it
first? Follow-up: Why? How could these testing opportunities be increased?
5. Would you say it is important for such a database that other users share their
experiences with the database? Follow-up: Why/why not? How could the sharing of
experiences regarding the database be increased?

III. End of interview

-Do you have any additional remarks regarding how a database could improve healthcare?
-Could you tell us the names of local authorities at other municipalities and do you have their email-address?

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 Appendix C. Importance of independent variables & indicators
Municipaliti Municipality Municipalities that did not hear Majority
Indicators es that heard that heard about database Count
about about database
database & & did not
adopted adopt

R5 R2 R4 R7 R1 R6 R3 R8 R9

Willingness to + + + + + + + + + 9*+
adopt

Relative + + + + + + + + + 9*+
Relative Advantage
Advantage (Importance)

Cost reduction - - 0 0 0 0 0 0 0 /
(Importance)

Efficiency + + + + 0 + + 0 0 6*+
(Importance)

User- 0 + 0 0 0 0 0 0 0 1*+
friendliness
(Importance)

Contribution to 0 + + 0 0 + + + + 7*+
health
intervention
(Importance)

Image 0 - 0 0 0 0 0 0 0 /
(Importance)

Compatibility + + + + + + + + + 9*+
Compatibility (Importance)

Adjustments of - - 0 0 0 0 0 0 0 /
skills &
practices
required
(Importance)

Adjustments of - - 0 0 0 0 0 0 0 /
skills &
practices
difficult
(Importance)

Fit with values - + + 0 + 0 0 0 + 4*+

and morals
(Importance)

Complexity + + + + + + + + + 9*+
Complexity (Importance)

New - - - 0 0 0 0 0 0 /
knowledge
required
(Importance)

30
 Quality of + + + 0 0 0 0 0 0 3*+
existing
knowledge
(Importance)

Self- 0 + + 0 0 + + + + 6*+
explanatory
functions
(Importance)

Support for 0 - - 0 0 - 0 0 - /
learning use
(Importance)

Trialability - - - - - - - 0 - 8*-
Trialability (Importance)

Opportunities - - - 0 0 0 0 0 0 /
for trying
(Importance)

Prototypes for - - - 0 0 0 0 0 0 /
trying
(Importance)

Difficulty of - - - 0 0 0 0 0 0 /
trying
(Importance)

Guidance - - - 0 0 0 0 0 0 /
(Importance)

Observability + - + + + + + + + 8*+
Observability (Importance)

Existence of + - 0 + + + + + + 7*+
other users that
communicate
about benefits
of database
(Importance)

Influence + - 0 + 0 + 0 0 0 3*+
through other
users
(Importance)

Communication + + + + + + + + + 9*+
Communicatio channels
n channels (Importance)

Amount of - + + + 0 + + + + 7*+
available
channels
(Importance)

Strength of - - - - 0 - - - 0 /
relations
(Importance)

Degree of 0 0 0 0 0 0 0 0 0 /
homophily
(Importance)

31
Breadth of used 0 + 0 0 0 0 0 + 0 2*+
channels
(Importance)

Effort spent on + + + + 0 0 + + 0 6*+

promotion
(Importance)

Fit of 0 0 0 0 0 0 0 0 0 /
marketing
strategy
(Importance)

32