Provider Behavior Change: Social and Behavior Change Approaches to Quality of Care in Family Planning

"An SBC [social and behaviour change] approach within PBC [provider behaviour change] to improving quality of care in family planning addresses behavioral antecedents of provider behavior and has the potential to result in multiple impacts at individual, community, and system levels."

Providers' behaviours can significantly influence patients' experiences of services, their likelihood to adhere to treatment or recommendations, and the possibility they will re-engage with health services for improved health outcomes. Provider behaviour change (PBC) interventions often address provider knowledge and competency and/or might attempt to mitigate structural and contextual barriers that influence provider behaviour, but information on the pathways that PBC interventions take to achieve their intended objective is sparse. This research brief highlights evidence, insights, and learnings from the work (2017-2023) of the United States Agency for International Development (USAID)'s Breakthrough RESEARCH to fill PBC evidence gaps and to advance PBC programming.

Breakthrough RESEARCH reviewed the evidence on the promise of behavioural economics to improve health outcomes through provider-facing interventions in 5 health areas: family planning; maternal, newborn, and child health; malaria; child nutrition; and HIV/AIDS. (The focus of the research brief is on family planning.) A user guide within the research brief helps to inform decisions about designing and adapting programmes to maximise impact and shaping the research agenda to fill gaps in understanding provider behaviour.

A Breakthrough-RESEARCH-led review of insights from recent research and design activities from Breakthrough RESEARCH, Breakthrough ACTION, and other projects across 9 low- and middle-income country (LMIC) settings sheds light on the behavioural roots of challenges healthcare providers face in providing high-quality services. For example, like all human behaviours, family planning provider behaviours are influenced by hierarchies and inequitable norms in health, social, economic, and gender spheres that intersect. Power, defined as the capability to make a choice or act in a particular way for oneself and for others, often derives from various sources and may be expressed differently across health provider cadre and provider-client relationships. Integrating power-enhancing approaches in PBC programming, including for family planning quality of care, can improve collaboration and feedback among providers and offer structural changes for quality.

Five insights and evidence-informed design tactics to support provider behaviour that are applicable for family planning service delivery include:

1. Integrate cues to important but neglected aspects of care into the signs, forms, and markers that providers are exposed to in their day-to-day work.
2. Build tools and channels through which providers can learn from their daily experience and that motivate them to consider unanticipated effects of their actions.
3. Match clinical guidance to the practical environment, and make correct provider behaviour the easiest one - both practically and psychologically.
4. Enable providers to reconcile their personal identities and past experiences with their professional obligations.
5. Alleviate workload burden by reducing hassles and inefficiencies thoughtfully, shifting responsibilities, and recentring attention toward what is within the provider's control.

PBC is difficult to measure, but the PRECEDE-PROCEED Model measures five key domains: (i) predisposing factors: an individual's attitudes, beliefs, and perceptions; (ii) reinforcing factors: those that follow a behaviour and that determine whether, for example, a health worker receives positive (or negative) feedback from supervisors; (iii) enabling factors: resources and skills required to make desired behavioural and environmental changes (e.g., availability of medical supplies); (iv) ability: competency and skills of the provider; and (v) provider behaviour/client-provider interactions: client reception, person-centred care, and clinical management. The Provider Authoritarian Attitude Scale [PDF] developed by Breakthrough RESEARCH is meant to facilitate understanding of provider-level factors affecting family services and help programmes identify and monitor programmatic needs, recognising items in the scale may need to be adapted to new local contexts.

Breakthrough RESEARCH worked with SBC implementing partners to develop a series of interactive research spotlights, one of which explores Pathfinder International's Beyond Bias project (see Related Summaries, below). This spotlight features the human-centred design (HCD) approaches to address provider bias at family planning public clinics in Burkina Faso and Tanzania and at private clinics in Pakistan. Beyond Bias developed a Provider Bias Driver Tree, a set of drivers aggregated into three distinct categories: (i) biases specific to providers and youth clients (biographical); (ii) situational factors; and (iii) broader social or cultural effects. Examples of drivers of provider bias identified were:

• Lack of understanding of youth needs and poor communication in provider-youth interactions;
• Disincentives to work with adolescents because they require more time and sensitivity;
• Incorrect guidance on side effects and fertility risks of contraception for youth, particularly for long-acting hormonal methods;
• An empathetic, protective, parental attitude that can lead to discrimination against youth; and
• Heavy workload and stress, which may exacerbate existing biases.

The research brief concludes with several calls to action, noting that future PBC approaches to improve the quality of family planning services should commit to robust evaluation of PBC interventions (e.g., those that address providers' attitudes and biases) to support policymakers in targeting quality improvement and investing in evidence-based behaviour change programmes.