© 2004 Lippincott Williams & Wilkins, Inc.
, Philadelphia
Theoretical Framework
A Model for Cancer Care
This article presents an organizing framework for developing
countries to facilitate the development and implementation of
educational initiatives to advance cancer care in an effort to
effect global health in developing countries. The framework
used to design this program was based on the classic work of
Donabedian, who identified the structure, process, and out-
come trilogy as essential components.30 Structure refers to the
tools and resources that participants have at their disposal to
accomplish their work and the organizational settings in which
they work and practice. Structure encompasses the number,
distribution, and qualifications of professional personnel as
well as size, equipment, and geographic disposition of the facil-
ities used to provide care. Structure goes beyond elements of
production to include the manner in which the delivery of the
program to provide care is organized, both formally and infor-
mally. Structure is characterized by the fact that it is relatively
stable, it functions to produce care, and it influences the kind
of care that is provided.
Process refers to a set of activities that go on within, among,
and between participants and their clients. Technical and
interpersonal aspects comprise the process component of the
framework. Technical components refer to the application of
science and technology in a way that maximizes benefits to
health without increasing risks. The interpersonal domain
refers to the social and psychological interaction between par-
ticipants and clients.30
Outcomes represent the consequences of the process on
the health and welfare of recipients. Specifically,
Donabedian30(pp82–83) used the word outcome to mean a
“change in a client’s current and future health status that can
be attributed to antecedent healthcare.” Donabedian concep-
tualized outcomes to include physical as well as social and psy-
chological function. In addition, he considered client atti-
tudes, including satisfaction, health-related knowledge, and
health-related behavioral change to be important outcome
variables.
10S ■ Cancer Nursing™, Vol. 27, No. 6S, 2004

Application of the Model to the
Cancer Program for Developing
Countries
In this program, the structural elements included the National
Cancer Institute of NIH, the funding agency, the 71 developing
countries, the program faculty, and the participants representing
their countries. The 2- to 3-day pre-conference workshops prior
to an international cancer nursing meeting also represented
structural variables. Process elements included the content of the
cancer prevention and control program and the interactions that
transpired among the faculty, participants, and personnel in
their work settings and leaders in administrative positions in the
developing countries. Outcomes of interest included the partic-
ipants’ knowledge, attitudes, implementation of program con-
tent, and, ultimately, behavioral changes related to improved
health. A brief description of each of the structure, process, and
outcome components is presented in Table 5.
Within such a framework, people are encouraged to orga-
nize themselves within their communities to improve their
own health and the health of others. It is well recognized that
there is enormous variability between countries (and even
within countries) as to the rates and causes of morbidity and
mortality.31 Similarly, it is recognized that interventions cho-
sen at a global level cannot be responsive to such a variety of
underlying causes, and an individualized approach is needed.
One of the first steps in the process is to define the burden of
disease within a country and identify interventions that have
been proved to be effective.32 Once the structure and outcome
components of the framework are established, then the partic-
ipants need to operationalize the process. For this program, the
process used to disseminate the content was through diffusion
because it was directed at the individual level.
Diffusion occurs when “an innovation is communicated
through certain channels over time among members of the
Theoretical Framework
 Table 5 • Application of the Model for the Development of Cancer Programs for Developing Countries
Structural variables
The National Cancer Institute (NCI) A federal organization within the National Institutes of Health that funded the
grant proposals submitted to develop and implement the cancer program.
The grants were peer-reviewed by scientific review committees.
Characteristics of developing countries Participating countries in this program recognized the importance of cancer care
but had varied levels of cancer initiatives in their countries, from none to
beginning educational levels.
Characteristics of principal investigation and Program faculty in this program were expert oncology nursing leaders, educators,
program faculty researchers, and clinicians with established training programs in cancer care.
Characteristics of participants Participants in this program included primarily nurses (including a few physicians)
who were selected to participate because of the position they held in their
country, which could potentially influence the trialability and adaptation of
content within the program.
Characteristics of the program Initially the program was developed on the basis of the national guidelines for
prevention and detection of common cancers worldwide. The program was
expanded to include cancer control content, including palliative care and
pain management.
Process variables
Cancer care The participants attended 2 face-to-face preconference international workshops.
These workshops were designed to facilitate the adoption of the content and
development of similar programs in part or completely in their own countries.
Participants were required to develop a contract that outlined specific activities
related to the program they expected to accomplish. Participants were required to
submit written and oral reports at the second workshop.
Outcome variables
Participant outcomes Participants reported their knowledge, attitudes, and behaviors related to cancer
prevention, detection, and control content on standardized measures.
Participants evaluated personal and professional goals at the beginning and
at the end of the program and yearly over 2 years. Included as outcomes were
participants’ ability to develop and implement related programs in their countries
and changes in their own personal health behaviors, e.g., smoking cessation, first
Papanicolaou smear, first mammogram.
Program outcomes Programs were evaluated by participants on several outcomes: effectiveness of
meeting program objectives, faculty presentations, location and schedule of the
program, attendance at 2 preconference workshops, and completion of yearly
follow-up materials.

social system.”33(p14) Thus diffusion has several components.
1. It is a communication process that takes place through
channels.
2. It is directed to specific members of the social system.
3. It introduces something new into the system that reduces
uncertainty about some key activity within the social system.
Innovation diffusion was developed by Rogers,33 who con-
ceived the individual as the adopter. We further operationalized
the process component to include diffusion of the innovator.
An individual’s decision to adopt an innovation is usually
reached in a series of four steps. In the first step, knowledge,
targeted individuals become aware of the innovation and begin
to associate it with needs or activities to which it is relevant,
and to an agenda, either personal or organizational. In knowl-
edge step, the complexity of the innovation and information
about how it can be used are important. Complexity influ-
ences the adopter’s assessment of how easily it can be imple-
mented. It also refers to the understandability of the underly-
ing principles that govern how the innovation is used and
under what circumstances. Clearly, professional judgment is
required to assess whether the innovation is sufficiently
advanced and tested to be considered for implementation.
Another characteristic of the innovation that is important at
the knowledge step is its compatibility or its relevance to other
activities that are part of the core tasks of the organization. The
important sources of information tend to be objective and
impersonal.
The second step in the process is persuasion. At this step other
features of the innovation become significant, namely, its observ-
ability and technical advantage relative to standard practice. If the
innovation is complex and apparently varying from accepted ideas,
its justification by significant individuals in the profession may
resolve or reduce uncertainty. However, the motivation to imple-
ment such a change will depend upon evidence that individuals
such as those in the target audience have experienced success in

Theoretical Framework Cancer Nursing™, Vol. 27, No. 6S, 2004 ■ 11S
 Figure 2 ■ Model describing components of theoretical framework.
implementing it. Thus, at this stage the local influential opinion
leaders in that community who are well known and viewed as suc-
cessful are most likely to be able to persuade others to try the inno-
vation.33,34 The effects of the innovation are assessed through
tangible results. Traditionally, these have included reduced mortal-
ity or morbidity, improved access to critical resources, improved
cost/ benefit ratios, or a combination of these.
The third step in the process is the decision about whether
the innovation will actually be implemented. Innovations that
can be adopted on a trial basis are more likely to be adopted.
The trialability is determined by whether the target audience
has the resources to implement the innovation and how per-
manent the initial decision has to be. Thus, if the innovation
can be tried at no great risk to the adopter, and if there are
resources available to the initiator or the organization to sup-
port trial use, it is more likely to be adopted than if such
resources are scarce and/or the decision once made is difficult
to reverse. The decision to adopt an innovation occurs over
12S ■ Cancer Nursing™, Vol. 27, No. 6S, 2004
time and leads to the fourth step, confirmation. Because adop-
tion is an ongoing process, this final step is not fully attainable.
Its incorporation in the model serves to emphasize that the
adoption of an innovation is always conditional on the basis
that the innovation makes a contribution to the core activities
of the organization or the individual making the decision to
adopt. Thus, adoption implies an initial decision, which then
must be confirmed by continued experience, leading to sus-
tainability. There is the possibility that the adopter will revert
to earlier practice or replace the innovation with something
even more innovative.
In order for individuals and communities to adopt the
innovation and content of the program to bring about
change, the formation of partnerships of key participants
within developing countries is needed so collaboration
evolves. In Figure 2, a description of each component within
the framework and how it has been operationalized and mea-
sured for its impact is summarized.
Theoretical Framework