Frameworks, lyrics and non-adoption of technology

Frameworks, lyrics and non-adoption of technology

You know that feeling when a piece of music (or a book or film) resonates so strongly that it helps you understand something about your life? In my late teens it was The Smiths who did just that. I suspect that teenage hormones may have been a factor, but every lyric from Morrissey’s pen seemed to speak to me directly.

Fast forward to 2018, and minus the heady mix of adolescent intensity and the tunes, I had a not altogether dissimilar sensation reading Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies by Trisha Greenhalgh et al (2017). This paper felt like reliving the first four years of my journey into the digital health technology sphere – every challenge, mistake, obstacle we have encountered is captured in this compelling paper on why technology doesn’t get adopted in the NHS. It felt a bit like the life story of mHabitat but minus the highs…

NASSS is an evidence based and theory informed framework that endeavours to set out the interrelated factors that influence the non-adoption abandonment, scale-up, spread or sustainability of technology. It aims to be a tool that can easily be used in practice. The rich blend of research methods comprising case studies with qualitative interviews and ethnography, along with a review of the literature, elicited the seven framework themes (see the diagram above).

Our tacit experience of non-adoption could have easily have been one of these case studies – everything from poor clarity of the problem the technology is meant to solve; poor infrastructure; non-permissive policies; lack of capacity in teams; changing personnel; the impact of restructures; lack of training/support for implementation; unanticipated changes to workflow; lack of interoperability; shifting priorities; no business/sustainability model; bugs and problems with software – the list goes on.

However, far more interesting to me are the factors which often receive less attention – such as the interplay between people and technology, ethical issues and the impact of the socio-determinants of health. These are the sorts of themes we endeavoured to get to grips with during our Digital Humanity in Health and Care seminar series last year. They are important issues which can make the difference between adoption and non-adoption, but which can be underplayed in the tech-determinist trajectory of digital in health.

The authors propose that NASSS could be applied in technology innovation within health and care in the the following ways:

  1. To inform the design of a new technology
  2. To identify technological solutions that have a limited chance of achieving large-scale, sustained adoption
  3. To plan the implementation, scale-up, or rollout of a technology program
  4. To explain and learn from program failures.

We are exploring how we can use the NASSS framework to inform early discovery in the design of new technologies. We’re big fans of building adoption into the earliest design and/or deployment of a technology. It is not uncommon to be approached by practitioners who have what appears like a great idea to solve a problem with technology but very little sense of the complexity associated with design and development, never mind getting it deployed and adopted.

We are keen to incorporate the seven components of the framework as part of our initial discovery work with teams to help them evaluate the potential of their ideas – a tool for deliberation and reflection that enables people to develop a nuanced appreciation of the journey in front of them before they decide if or how they embark upon it.

When I was a teenager there was something reassuring about hearing my innermost feelings about the world expressed through the lyrics of a musician. It is not so dissimilar seeing my experiences in the sphere of digital technology in health and care validated by this empirical piece of work. However, this in itself may be a damning indictment of middle age – who knows…

Nb. other recent useful publications about the challenges to adoption of innovation in the NHS can be found by The King’s Fund and The Health Foundation.


  1. What really counts – keeping humanity at the heart of digital innovation | co-design digital health and wellbeing - […] – what it will restore, replace, enhance or mutate into. The NASSS framework which I’ve previously blogged about encourages…

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