Provider Behavior Change Approaches to Improve Family Planning Services in the Ouagadougou Partnership Countries: A Landscaping Review

"...appear promising regarding their expected impact on provider behaviors and client outcomes..."

Effective client-provider interactions are considered essential for consistent demand and uptake of family planning (FP) services. To that end, recent projects in Francophone West Africa (FWA) have investigated barriers to effective service provision that call for a focus on provider behaviour change (PBC). It is increasingly recognised that provider behaviour is influenced by factors beyond their clinical training that fall within the purview of social and behaviour change (SBC), including social norms, attitudes, cognitive biases, and motivations. From Breakthrough RESEARCH, this landscaping review shares evidence (as of 2020) on the effectiveness of PBC interventions for improving FP services in the Ouagadougou Partnership (OP) countries of FWA.

This landscaping builds upon two global reviews of the effectiveness of PBC interventions, the findings of which are summarised to orient the reader. The present review entailed a literature search (2000 to 2020) and interviews conducted from August through September 2019 with representatives from organisations working on PBC. For purposes of this review, PBC interventions include interventions that go beyond clinical training and support (e.g., technical job aids) and seek to positively influence provider behaviour to improve the quality of services, enhance client experiences, increase demand for services, and increase uptake of commodities or adoption of healthier behaviours.

The literature search yielded a total of 18 documents including 17 evaluations of PBC interventions in 7 of the 9 OP countries, with 11 documents found in grey literature and 7 found in published literature. Table A.1 summarises the evaluation studies, the PBC approaches used, and the study outcomes (see Appendix 2f in this 14-page appendix document [PDF]). Overall, the researchers found the strength of the evidence on effective PBC approaches in the OP countries to be weak.

Of the 17 studies, most (13 studies) addressed structural and contextual barriers, as well as knowledge and competency barriers (13 studies). Fewer than half (6 studies) addressed attitudinal barriers. Here are a few select findings shared in the report:

• Supervision, training, and values clarification approaches typically addressed knowledge/competency and attitudinal barriers. For example, the ACQUIRE Project in Guinea combined training and education, managerial approaches, organisational changes, individual process improvements, and supplementary patient-facing materials. The intervention involved updating provider knowledge of long-acting and permanent methods (LAPMs) through training and addressed other provider behaviours via approaches such as clarifying job expectations, providing facilitative supervision, updating communication materials, and developing job aids. The intervention, which also included demand-side activities with clients, succeeded in increasing intrauterine device (IUD) use among clients, resulting in an increase of couples' years of protection from 130 in 2004 to 2,450 in 2006.
• Regulations, policies, and updates most often addressed knowledge/competency or structural/contextual barriers. For example, in Senegal, a new treatment protocol for post-abortion care in district health centres was complemented by supervisory visits and a tool that enabled providers to identify problems and develop follow-up action plans; 94% of clients reported being satisfied with services after the intervention.
• Infrastructure, supplies, and workload approaches also tended to address knowledge/competency or structural/contextual barriers. For example, an intervention in Niger included the integration of FP services into other health centre activities to make consultations more responsive to patients' needs. In addition, in order to overcome provider attitudes or biases that may act as barriers to FP access, policies were instated that mandated that providers must offer contraceptives to all women attending child health, antenatal, and postnatal care visits. Providers were also trained in interpersonal communication and were taught how to engage in dialogue on contraceptives with clients. The intervention resulted in an increase in FP uptake among eligible female clients presenting at the health centre from 1% to 29%.
• Incentives addressed structural/contextual and attitudinal barriers. For example, financial incentives were used as a PBC approach in Senegal to improve the quality of a variety of health services. A qualitative evaluation found that the intervention improved provider behaviour and quality of care and helped transform organisational culture toward more responsive care.
• Social accountability approaches, which were combined with managerial approaches, addressed structural/contextual and attitudinal barriers. One study in Mali built the capacity of providers and connected providers to communities for dialogue about power dynamics and the definition of quality services. Community reflections expressed during these meetings were documented and incorporated into plans of action for the providers, who were routinely monitored. There was a reduction in community complaints from 400 in 2016 to 47 in 2018, and, across the intervention period, there were 57,777 new FP users, a majority of whom used long-acting reversible contraceptives (LARCs).

Two case studies highlight examples of current projects addressing provider behaviour, including evaluation results, challenges, and lessons learned. In brief:

1. Quality Assurance Project in Niger: Camber Collective and Animas Sutura - Camber Collective aimed to improve the quality of the client–provider interaction by giving providers tools including counseling cards and flip charts, providing communication training, and implementing monthly supportive supervision visits. The organisation also developed a tool to segment clients during FP consultations to identify homogenous groups that are receptive to certain counseling messages. In collaboration with Animas Sutura, a pilot project was conducted in 36 primary health centers (12 pilot intervention, 24 comparison) in Maradi and Tillabéry, Niger. Results indicated that pilot sites showed improvement in indicators of all six categories compared with control sites at endline. Among key lessons for implementation: Set up focal points to ensure coaching at each facility, establish quality assurance teams, and create information-sharing systems to ensure better communication throughout the health system.
2. Beyond Bias in Burkina Faso: YLabs, Camber Collective, and Pathfinder International - Using a human-centred design approach, YLabs and Pathfinder developed a 3-part adaptive solution to address provider bias, which was carried out at public clinics in Burkina Faso and Tanzania and at private clinics in Pakistan. For example, a multi-week ongoing peer learning forum called "Connect" was designed to support providers to apply unbiased practices in their day-to-day work, address technical misinformation, and provide a space for ongoing group problem-solving. The results from Beyond Bias's prototyping phase suggest that an integrated behaviour change strategy to address provider bias is crucial. Encouraging empathy among providers toward youth is key to reducing bias in the client–provider interaction but must be paired with structured reflection and clear, measurable targets with the promise of social recognition for providers to commit to action. The Beyond Bias project developed a new framework for assessment of bias called the "Six Principles of Unbiased Care".

In addition to a summary of the findings, the report offers a series of recommendations - in the categories of geographic distribution, research and study design, barriers addressed, outcomes assessed, PBC approaches, programmatic documentation, vulnerable populations, and cost/cost effectiveness. Here are just a few examples:

• PBC programmes should conduct and document formative work to understand the social and gender norms that influence provider behaviour. More evidence is needed to understand whether normative approaches, such as values clarification, can improve the quality of providers' interpersonal communication with clients.
• Further research is needed to understand whether improving the behaviours/practices of health providers influences the quality of care provided and to identify the most effective SBC approaches to improve quality of care. PBC programme implementers and evaluators should assess changes in quality of care from multiple perspectives.
• SBC implementing partners should apply approaches that empower providers to identify problems and create solutions in varying settings to see whether improvements in organisational culture occur across settings.
• Because provider bias has been found against young women and those who have not borne children in FWA, evaluations of programmes addressing provider bias should collect disaggregated data to allow for subgroup analysis.
• Programmes should share lessons learned so that the evidence base can provide a more robust understanding of what PBC approaches work and do not work in different settings and with different types of providers.