The Drum Beat 825 - Provider Behaviour Change

• 1.Provider Behavior Ecosystem Map
• From Breakthrough ACTION, this ecosystem map is designed to help social and behaviour change (SBC) and service delivery practitioners, donors, and researchers appreciate the wide-ranging factors that shape health facility-based provider behaviour so they can design and implement more effective, supportive PBC initiatives. [Feb 2021]
  
   
• 2.Strategies for Changing the Behavior of Private Providers
• Private providers outside government are often the first line of health care in developing countries. This primer was designed as a resource for field staff who implement private PBC programmes designed to increase the appropriate use of healthcare products and services. It describes applicable behaviour change theories (behavioural economics, the ecological model, and the stages of change model) and outlines factors that influence provider decisionmaking. [Feb 2016]
  
   
• 3.Provider Behavior Change: Social and Behavior Change Approaches to Quality of Care in Family Planning
• This research brief highlights evidence, insights, and learnings from the work (2017-2023) of Breakthrough RESEARCH to fill PBC evidence gaps and to advance PBC programming. A 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. Five evidence-informed design tactics to support provider behaviour that are applicable for family planning service delivery are offered. [Jan 2023]
  
   
• See also:
  
  Evidence Review and Analysis of Provider Behavior Change Opportunities

• 4.Effect of Exposure to Visual Campaigns and Narrative Vignettes on Addiction Stigma Among Health Care Professionals: A Randomized Clinical Trial
  
  by Alene Kennedy-Hendricks, Emma E. McGinty, Amber Summers, Susan Krenn, et al.
• Stigma occurs when the processes of labeling, stereotyping, status loss, and discrimination are enforced through power differentials. Stigma (and/or the anticipation of it) in a healthcare context may exacerbate patient mistrust, result in diminished care-seeking, and compromise the quality of care. For example, among clinicians, higher levels of stigma have been associated with less interest in prescribing medication to treat opioid use disorder (OUD). This study evaluated the effect of OUD-related messages delivered by different messengers on stigma and attitudes toward people with OUD among healthcare professionals, finding that clinicians who received both the visual campaign and a narrative vignette had more positive OUD-related views and language. Developed in tandem with the study, the Reducing the Stigma of Addiction website outlines the effects of addiction stigma, including a list of words to use and not to use, and asks clinicians to take a "Words Matter" pledge. [Feb 2022]
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• 5.Beyond Bias
  
  The 3-year Beyond Bias project worked in Burkina Faso, Pakistan, and Tanzania to design and test scalable solutions that address provider bias, such as a belief that young, unmarried people should not be sexually active or that young, married women should prove fertility. Key tips for addressing bias that emerged from this project, which was led by Pathfinder International, in collaboration with Camber Collective, YLabs, and Behavioral Economics in Reproductive Health (BERI) and with funding from the Bill & Melinda Gates Foundation, include: Name bias, but don't shame bias; acknowledge constraints, and activate agency; reward growth over good; connect bias to what providers care about; and celebrate providers' knowledge, experience, and commitment.
  
   
• 6.Stigma Reduction Training Improves Healthcare Provider Attitudes toward, and Experiences of, Young Marginalized People in Bangladesh
  
  by Scott Geibel, Sharif M. I. Hossain, Julie Pulerwitz, et al.
• Stigma and discrimination can inhibit youth uptake of HIV and sexual and reproductive health and rights (SRHR) services. In Bangladesh, studies have documented avoidance of services by people living with HIV (PLHIV) due to fear of potential discrimination, as well as high levels of discriminatory behaviour by health workers. Marie Stopes Bangladesh (MSB), in partnership with Link Up, trained over 1,000 MSB providers on youth-focused SRHR. Data indicate changes in key stigma-related indicators. For example, agreement that PLHIV should feel ashamed of themselves decreased significantly after the initial training (35.3%-19.7%; p < .001) and remained stable after the supplemental stigma training. The percentage of clients who reported being dissatisfied with services decreased from 3.4% after first training to 0% after the second training. [Feb 2017]
  
   
• See also:
  
  Comprehensive Package for Reducing Stigma and Discrimination in Health Facilities

• 7.Expanding Access to Intrauterine Device Services in India (EAISI) Project
• In 2015, EngenderHealth worked to increase demand for and improve the availability, quality, and sustainability of intrauterine device (IUD) services in Gujarat and Rajasthan, India. Activities focused on: advocacy with policymakers and programme managers; sensitisation and capacity-building of providers; and use of data for decision-making. For example, EngenderHealth provided a competency-based training to support client-centred counseling through which providers explore the client's individual circumstances (including their social and gender context), identify challenges in implementing FP decisions, and determine approaches to address such challenges. The training highlights the power imbalances that clients face within their households and communities and at facilities in a patriarchal society like India. An assessment showed that the majority (>80%) of the service providers trained reflected attitudes that were gender-sensitive, non-discriminatory, and respectful of clients' rights and choices.
  
   
• 8.Provider Behavior Change Toolkit: Family Planning Focus
• This Breakthrough ACTION toolkit supports the design, implementation, and evaluation of facility-based PBC initiatives within family planning (FP) and reproductive health (RH) programmes. It guides users through an empathy-focused, 4-step process that supports providers, clients, and district health teams in identifying and prioritising the root causes of provider behaviour and generating locally appropriate solutions. The toolkit employs a systems lens and uses a multi-level approach to gather perspectives and input on provider behaviour from a variety of stakeholders. It positions providers as part of the inquiry and solution development process rather than as part of the problem. [Jul 2022]
  
   
• 9.Empathways
• Developed by Breakthrough ACTION, Empathways is a 3-round card deck designed to spark discussion and joint reflection between young people and FP service providers. The tool aims to develop provider empathy for young clients and to encourage providers to pull from this empathy to deliver more youth-centred FP and contraceptive services. [2021]
  
   
• 10.Qualitative Assessment of Providers' Experiences with a Segmentation Counseling Tool for Family Planning in Niger
  
  by Ellen MacLachlan, Balki Ibrahim Agali, Amelia Maytan‑Joneydi, Sanoussi Chaibou, Souleymane Amadou Garba, Illiassou Chaibou Halidou, Ilene S. Speizer, and Abdoul Moumouni Nouhou
• Niger has long been recognised as a country with high fertility and low contraceptive use. From 2013-2014, the government developed a segmentation counseling strategy that involves segmenting women into one of 5 categories of FP user and counseling them accordingly. While providers in the Dosso region of Niger acknowledged that the segmentation approach added time to the clinic visit, they did see the benefit of this extra time in providing more meaningful interactions between clients and providers, allowing an opportunity to ask more questions, and leaving clients with a deeper understanding of FP and of the different methods available. Half the providers stated that women learned about the segmentation approach from other women in their communities, and their interest in FP grew from there. [May 2023]
  
   
• See also:
  
  Provider Behavior Change Approaches to Improve Family Planning Services in the Ouagadougou Partnership Countries: A Landscaping Review

• 11.Building Trust and Empathy Around COVID-19
• Breakthrough ACTION-Nigeria implemented several data-driven SBC interventions designed to support the Government of Nigeria in increasing COVID-19 vaccine uptake by addressing and overcoming vaccine hesitancy, including among health care workers (HCWs). Many HCWs have themselves had negative personal experiences when they were clients interacting with the health system. Therefore, the training focuses on empathy, self-care, and the well-being of HCWs. It aims to not only build the skills of HCWs in providing empathetic care but also support them in navigating their own self-care to avoid burnout during an emergency. [Feb 2023]
  
   
• 12.Caring for Providers to Improve Patient Experience (CPIPE): Intervention Development Process
  
  by Patience A. Afulani, Edwina N. Oboke, Beryl A. Ogolla, et al.
• The concept of person-centred maternal care (PCMC) - care that is respectful and responsive to individual women's preferences, needs, and values - is not equally experienced by all women: The most vulnerable groups tend to receive the poorest care. Disrespectful, abusive, and neglectful treatment of women during facility-based childbirth deters women from giving birth in health facilities. The intervention discussed in this paper, Caring for Providers to Improve Patient Experience (CPIPE), focused on two factors - provider stress and implicit bias - that drive poor PCMC and contribute to disparities in PCMC. This paper examines the iterative design process of the CPIPE intervention, which is a culmination of over 6 years of engagement in Migori County, Kenya. [Dec 2022]
  
   

• 13.Addressing Behavior Change in Maternal, Neonatal, and Child Health with Quality Improvement and Collaborative Learning Methods in Guatemala
  
  by Elena Hurtado, Lilian Ramírez, and Pablo Moreira
• This book chapter describes how 2 projects in Guatemala, both funded by the United States Agency for International Development (USAID), applied quality improvement (QI) principles and methods to social and behaviour change communication (SBCC) interventions. QI has been mostly associated with improving clinical care; in the case of the projects described here, leaders and stakeholders were convinced that QI elements, such as the plan-do-study-act (PDSA) cycle and collaborative learning methods, could also work to improve SBCC interventions. Most indicators showed increases after successive QI cycles of measuring, planning, trying out changes, and adopting those that resulted in improvement. One example of an activity community QI teams carried out to achieve these outcomes: developing key messages and talks on the ideal inter-pregnancy interval for use at every clinic visit and during household visits. Since the project, QI methods and tools are being used by other cooperating agencies and projects. [May 2020]
  
   
• 14.Can a Quality Improvement Intervention Improve Person-Centred Maternity Care in Kenya?
  
  by May Sudhinaraset, Katie M. Giessler, Michelle Kao Nakphong, Meghan M. Munson, Ginger M. Golub, Nadia G. Diamond-Smith, James Opot, and Cathy E. Green
• This study aimed to understand whether QI collaboratives (QICs) could improve PCMC experiences for women delivering in 3 government-run health facilities in Kiambu and Nairobi counties, Kenya. PCMC places the woman and her family at the centre of care, involving her in decisions and respecting and responding to her needs, values, and preferences. All intervention facilities found the study's negative results surprising because of the general sense that the QI approach was helpful; however, they (along with the researchers) offered several explanations as to why the intervention may not have been successful - e.g., the fact that broader QI interventions, including effective communication and respectful maternity care, were occurring over the duration of the project from a variety of stakeholders. [Mar 2023]
  
   
• 15.Tested Solutions for Supporting Facility-Based Delivery
• Delivery in a health facility is an important strategy for reducing maternal and neonatal mortality, yet many women still face obstacles to reaching the facility and instead give birth at home or in the community. In 2021, Breakthrough ACTION undertook a project to address these challenges among rural low-income pregnant women in Liberia. The project, which was carried out in partnership with ideas42, conducted formative research and then undertook a collaborative co-design process that engaged local and national government stakeholders, pregnant and postpartum women and their families, and community and facility-based health workers. The result: 5 solutions, each of which is described in this tool along with considerations for adaptation. [Mar 2023]
  
   
• See also:
  
  * Barriers to Provision of Respectful Maternity Care in Zambia: Results from a Qualitative Study through the Lens of Behavioral Science
  
  * The Case for Using a Behavior Change Model to Design Interventions to Promote Respectful Maternal Care

• 16.Leveraging Connections Between Client and Provider Behavior: Behavioral Design for Provider Behavior Change in Care-Seeking for Children in Zambia
• Caregivers of children experiencing symptoms of illness do not always proactively seek care or follow through on referrals to a health facility. The problem of delayed care-seeking by caregivers may, on its surface, appear to be a client-side problem. However, research conducted by Breakthrough ACTION in Zambia suggests that caregivers' care-seeking behaviour is influenced by providers' behaviour, which shapes caregivers' expectations for quality and experience of care. This brief describes lessons learned from a Zambian project that applied a behavioural design approach that led to solutions such as co-creation of quality-of-care guidelines. As part of that process, a trained neutral facilitator guided a collaborative community-provider workshop whose focus was on building empathy between providers and community members. [Mar 2020]
  
   
• 17.Nourishing Connections
• This set of two booklets provides detailed instructions for community health workers (CHWs) to counsel mothers on child feeding in a compassionate way. The design process for these tools began with research in Kebbi State, Nigeria, with CHWs, caregivers, family members, and community members to better understand child feeding challenges from their perspectives. With these insights, Breakthrough ACTION and USAID Advancing Nutrition carried out an iterative design and testing (human-centred design) process that resulted in tools for transforming the way CHWs interact with caregivers and fellow community members around nutrition. [Mar 2023]
  
   
• See also:
  
  Behavioral Solutions for Child Feeding During and After Illness

• 18.A Mixed-Methods Evaluation of the Impact of a Person-Centered Family Planning Intervention for Community Health Workers on Family Planning Outcomes in India
  
  by Nadia Diamond-Smith, Claire McDonell, Ananta Basudev Sahu, Kali Prasad Roy, and Katie Giessler
• Ensuring that women are supported in making informed choices about FP methods and are treated in a respectful, autonomous, and communicative manner has been deemed essential, especially in places like India, which has a history of coercive FP programmes. This group of researchers developed a scale to measure person-centred FP (PCFP), producing a 22-item scale (e.g., the client being involved in the FP method choice) that they validated in a population of women seeking FP services at a facility in Uttar Pradesh (UP), India. The study then evaluated a training on PCFP for Accredited Social Health Activists (ASHAs) in Varanasi, UP, in an effort to validate the scale among women interacting with a CHW. Analysis found the scale to be valid. [Dec 2020]
  
   
• 19.Provider Behavior Change Implementation Kit
• This I-Kit provides step-by-step guidance on using social and behaviour change communication (SBCC) to change health provider behaviours related to motivation, attitudes, and norms, with the ultimate goal to improve client outcomes. Monitoring and evaluation (M&E) of PBC for two different providers, CHWs and facility-based providers (FBPs), is the focus of the final step of the I-Kit. "Motivation cannot be observed or measured directly and as a result, monitoring and evaluation must measure the key factors of motivation." For CHWs, these factors are defined as: connectedness, social status, social and gender norms, incentives and personal rewards, and personal attitudes and beliefs; for FBPs, they are defined as: self-efficacy, perceived place in social hierarchy/status, social and gender norms, rewards, and work environment. [Aug 2016]
  
   
• 20.How to Measure Provider Behavior Change Impact
• Developed by Breakthrough RESEARCH, this guide - with an accompanying free online course on the SBC Learning Central Platform - is intended to help programme planners and designers better understand PBC initiatives and their impact on service delivery and quality. The guide is also meant to advance measurement of PBC by providing frameworks and illustrative examples of how PBC measurement can inform programme planning and design. Finally, the guide offers ways to continue building the evidence base for PBC approaches and impact. [Jan 2023]
  
   

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