Although integrated health systems have been widely promoted around the world (1), the great disparity in technical capacity between primary health institutions or county hospitals and large urban hospitals has been identified as a key concern. In particular, the delays or limitations in the diffusion and utilization of effective and appropriate technologies within medical alliance have greatly halted the improvement of the technical capacity of lower-level health institutions, which not only restricts the due role of specific technologies in a wider range and weakens the overall service capacity of the health system, but also exerts extremely adverse effects on public health (2).

Taking hepatic contrast-enhanced ultrasound (CEUS), for example, as a rapidly developing ultrasound examination technology with high sensitivity and specificity for the early detection and diagnosis of liver cancer, expanding the implementation of hepatic CEUS is becoming increasingly prominent, especially in the grim context of liver cancer prevention and control (3). However, with its effectiveness and appropriateness have been well proven and widely recognized (4), the diffusion and utilization of hepatic CEUS among physicians are still not well established, even in cases that many member institutions of medical alliance are qualified or sufficiently competent to provide regarding technical services (5–7). This fact reminds us that there is a complicated process for a certain technology from the general acceptance to its widespread use in practice. To steadily promote the diffusion and utilization of the technology, more effort should be invested to deeply investigate the comprehensive influencing mechanism underlying this process.

As stated by knowledge-attitude-practice (KAP) theory, the process of human behavior change can be divided into three steps, namely, acquiring knowledge, generating attitudes/beliefs, and forming practice/behaviors (8). The cognitive change caused by knowledge acquisition does not necessarily lead to behavior change; it should first lead to a change in perception, and then change people's behavior through the change in perception (9). Similarly, physicians' knowledge or the cognition of hepatic CEUS needs to lead to the extensive conceptual changes in the aspect of the early detection and diagnosis of liver cancer, and then gradually change the technology utilization behavior of hepatic CEUS through practical activities.

With respect to the potential influencing factors underlying the KAP process, some classical theoretical models, such as the theory of planning behavior (TPB), theory of rational action (TRA), and technology acceptance model (TAM), have provided clues alluding to some factors at the technical and individual levels (10, 11). Many previous empirical studies on technology diffusion and utilization behavior have focused on the technology itself and the groups, such as medical staff who directly use the technology and have verified the association between the final technology utilization behavior and individual-level (or technology-level) factors (11–14). However, even having been proposed by organizational ready for change (ORC) theory that some organizational features (organizational culture [OC], structures, resource endowments, etc.) may create a more receptive context for technology innovation and change (15–17), it has not been subjected to extensive empirical research, which makes the comprehensive influencing mechanism of organizational factors on certain health technology utilization behavior remain largely unknown. Especially in the context of medical alliance with many health institutions and medical staff, to further expand the use of appropriate and effective technologies, the role of organizational atmosphere and organizational practice in the KAP process of certain technology innovation implementation still needs to be further explored.

Therefore, this study intends to take hepatic CEUS as an example and integrate the ORC and KAP theories to investigate the comprehensive influencing mechanism of organizational atmosphere and organizational practice on technology diffusion and utilization in the medical alliance. The results of this study will be not only help to clarify the influence path of organizational-level factors on the knowledge, attitude, and finally the utilization behavior of specific technologies in the integrated healthcare system, but also provide practical guidance for promoting the diffusion and utilization of corresponding technologies in the context of the medical alliance and improving the service capacity of the overall health system.

Under the current context of limited diffusion and the utilization of appropriate health technologies within an integrated health system (6, 32), it is essential to clarify the influencing path of organizational factors on the physicians' KAP of diffusion and utilization of corresponding technology, especially when the comprehensive influencing mechanism of organizational factors remain largely unknown. By taking hepatic CEUS as an example, this study integrated ORC and KAP theories to develop a hypothesized model, and further applied SEM to verify the influencing mechanism of organizational atmosphere and organizational practice on the physicians' KAP of diffusion and utilization of hepatic CEUS. The results of this study will benefit further diffusion and utilization of CEUS and other appropriate health technology within the integrated health systems.

On the one hand, some hypotheses respectively proposed on the basis of KAP and ORC were confirmed in this study. Consistent with KAP hypotheses and previous empirical research (33), this study showed that the physicians' knowledge of hepatic CEUS positively influences their attitude and practice toward corresponding technology utilization. Additionally, significant influence was detected from physicians' attitude to their technology utilization behavior. These results reminded us that some efforts, such as transmitting the knowledge of certain technologies and transforming the belief of corresponding technologies utilization, should be made previously to promote the occurrence of technology utilization behavior (9). Similarly, this study reported significant positive association relationship between organizational atmosphere and organizational practice, which was in line with ORC theory. It revealed that organizational atmosphere and organizational practice complement and promote each other. It is embodied in CEUS and other corresponding health technologies that to obtain financial support, personnel support, information support, training and learning, information communication and other aspects of organizational practice, normative OC and strong willingness to share technology are needed as support. Conversely, if the hospital establishes an effective SM and is willing to carry out systematic training and the learning of appropriate health technology practices, it can further promote the hospital to advocate technological innovation, continuously learn and absorb new technologies, and share technological knowledge and information with other medical institutions. Thus, in the process of preparing for the diffusion of technological innovation in hospitals, the importance between organizational atmosphere and organizational practice should be highlighted.

On the other hand, with respect to the impacts of organizational determinants on the factors at the individual level, this study demonstrated that organizational practice could positively predict the knowledge and practice of physicians in the diffusion and utilization of hepatic CEUS, and play a mediating role in their utilization behavior through knowledge. Besides, the significant direct impact of organizational atmosphere was detected on the physicians' attitude toward hepatic CEUS utilization.

In line with the findings of previous research that organizational practice including some concrete SM can directly motivate individual behavior (34). In addition, this study reported that physicians were more inclined to use hepatic CEUS under appropriate situation if they gained more organizational support for CEUS adoption. The underlying mechanism may be that organizational practice can act as an organizational assurance and implementation support agency by providing more funding support, delivering more updating information, and setting up innovation promoting department, which will subsequently stimulate the physicians' consciousness and subjective initiative of hepatic CEUS adoption and utilization (20, 35). In the mode of medical alliance in China, the relatively common loose mode of the medical alliance fails to sink effectively in human resources allocation and health technology, which is not conducive to the diffusion and utilization of technology (36). On the other hand, the compact medical alliance manages people and property uniformly, encourages physicians to provide medical service guidance to grass-roots institutions (36), further sinks and integrates high-quality medical resources. Additionally, some member institutions in compact medical alliance have even invited experts from superior institutions to hold salons and lectures to share their experiences and insights in CEUS utilization in clinical practice. This will not only improve the physicians' knowledge of CEUS and enhance their own ability, but also drive more physicians to participate in the practice of the diffusion and utilization of corresponding technology, which may be the plausible reason of organizational practice's significant indirect impact on their utilization behavior through knowledge.

Since organizational atmosphere is often considered as an invisible “public opinion environment” recognized and accepted by the public (37), it is not hard to understand that it will inevitably affect physicians' attitude toward the diffusion and utilization of corresponding technology. In addition to the significant impact of attitude on the final utilization practice as mentioned above, this study confirmed organizational atmosphere's significant indirect influence on physicians' hepatic CEUS utilization practice through the physicians' attitude. These results highlighted the importance of developing a good organizational atmosphere suitable for the diffusion and utilization of technology or innovation (38). Combined with the practice mode of the medical alliance in China, the atmosphere of health technology diffusion in the loose medical organization has not formed the common value of technology diffusion compared with the compact medical alliance (36), which fails to unite, motivate, and regulate the behavior of the hospital members. To be more specific, it is recommended that the common value of advocating technological innovation should be established on the basis of constructing close medical alliance. Especially for the medical alliance of liver disease, it is of vital importance of reaching a consensus within the medical alliance to encourage early diagnosis and early treatment for patients with liver cancer even those at a high risk of liver cancer. On this basis, the organizational values that actively advocate the innovation in the screening and diagnostic technology would be capable to develop, which will further improve the organizational readiness for the diffusion and utilization of corresponding technologies at the ideological level (35).

However, it is noteworthy that the organizational atmosphere cannot directly drive the change of physicians' hepatic CEUS adoption and utilization. The plausible reason may be that organizational atmosphere representing the hospital's mental readiness and preference for certain technology innovation is not the organizational practice, which includes some concrete supporting measures to directly promote the advent of individual behavior (39). Additionally, organizational atmosphere does not completely replace or represent the individual physicians' attitude or intention toward corresponding technology use, which are often deemed as important predictors of utilization behavior in classical TPB (40). This result implied that the practical effect of technology diffusion would be limited if merely taking the countermeasure for improving organizational atmosphere without any concrete organizational SM. According to the significant association between organizational atmosphere and SM as confirmed above, it would be wise to simultaneously provide some concrete supporting measures (such as, providing financial support, establishing full-time departments or personnel, and establishing information communication channels) to promote new technology diffusion and utilization while creating an organizational atmosphere to encourage technological innovation.

This study was strengthened by some features. First, the study was developed by integrating the strengths of previous ORC and KAP theories, which greatly expand the scope of theoretical utilization and pertinently bridge the knowledge gap of the influencing mechanism of organizational factors on the physicians' KAP of diffusion and utilization of appropriate health technologies. Second, the research results will not only contribute to promoting the diffusion and utilization of hepatic CEUS to a wider scope at certain institutions, but also provide insight for expanding the use of other appropriate health technologies within an integrated healthcare system. Third, the sampled hospitals came from Fujian and Jiangxi Provinces respectively with a high- and low-liver cancer incidence rate, which would improve the representativeness of the sample. Fourth, this study applied SEM to simultaneously determine the influence of several factors on the diffusion and utilization of certain technology (outcome variable), as well as their internal interactions, which made the result prediction more accurate and robust. However, there are also some limitations to this study. First, due to the effect of social desirability and personal subjectivity, the surveyed physicians may tend to make more positive evaluation of their own and hospital performance than the actual situation, which leads to the overestimation of hospital atmosphere, practice, and physicians' KAP. Second, due to the structural design and length limit of the questionnaire, it lacks objective indicators to measure the professional knowledge of physicians. Finally, further research can take more relevant factors into considerations, such as physician's expertise and other organization-level factors that affect the physicians' KAP of the diffusion and utilization of hepatic CEUS or other appropriate health technologies. Besides, we will further study the influence of corresponding variables in future research.

By taking hepatic CEUS as an example, this study verified the influencing mechanism of organizational atmosphere and organizational practice on KAP toward the diffusion and utilization of corresponding technology. It is recommended to develop an organizational atmosphere of advocating technology innovation within the medical alliance and its member institutions. Additionally, to further expand the technology use to a wider scope, it also highlights the importance of establishing organizational SM. Some concrete supporting countermeasures are strongly recommended, such as sharing up-to-date information on corresponding technology or innovation, allocating special funds and personnel for technology innovation diffusion, and providing more training and guidance for newly introduced technologies.

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.

Ethical permission was granted for this study from the Ethics Committee of Fujian Medical University (No. 2017-17). This study was conducted under the Declaration of Helsinki. A formal letter of cooperation was written to the directors of each selected medical institution and permission was obtained. All participants were informed about the study purpose, participation in the study was voluntary, and all responses were anonymous.

WL designed and conducted the project, contributed to grasp the subject, and revised the manuscript. JL carried out the data analysis and drafted the manuscript. WL and QD developed the questionnaire. All authors read and approved the manuscript before submission.

This research was supported by the National Natural Science Foundation of China (Grant Number: 71704026) and the Distinguished Young Scientific Research Talents Plan in Universities of Fujian Province (Grant Number: 2018B030). The funders had no involvement in study design, data collection, statistical analysis, and manuscript writing.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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