Health care provider behavior heavily influences the quality of health services and a client’s experience of care, particularly for women seeking care for family planning and reproductive health. But global health practitioners have lacked a shared understanding of provider behavior change interventions and what influences provider behavior in order to ensure the best outcomes for everyone.
A new commentary in the journal Global Health: Science and Practice led by the Johns Hopkins Center for Communication Programs suggests that the definition of who is a provider be broadened, that training alone won’t be enough to improve outcomes and that the narrative around provider behavior change must shift from “blaming” to supporting providers.
“The narrative around provider behavior change often frames providers as the ‘problem’ rather than partners in the solution,” says CCP’s Olivia Carlson, a program officer on the Breakthrough ACTION project and one of the lead authors of the commentary. “In reality, there are a number of factors external to the provider that influence their behavior and the quality of patient care, so that framing is highly demotivating.
“What we’re trying to do is support providers and work with them as partners to provide better care, which is what they want to do. Providers are trying to provide the best care that they can. We just need to create a better environment for them to succeed.”
Carlson says that provider behavior change interventions have often been corrective and focused on changing undesirable provider behaviors rather than promoting positive ones. Many such interventions have been narrow in their application, focusing on individual- or workplace-level behavioral drivers. What Carlson and her colleagues found in conducting a literature review is that traditional healers, pharmacists and community health workers need to be as much a focus of interventions as those in the health facility.
“Just providing people with knowledge isn’t enough to change behavior,” she says. “And it is a natural instinct to jump to recommending training when you’re trying to change provider behavior. But we know that pairing training with other types of approaches is much more effective. And sometimes training alone is really not effective.”
Client behaviors and characteristics also influence provider behavior, but often, interventions only address the provider or the client. In Tanzania, Breakthrough ACTION is piloting a package of client- and provider-side tools to help providers and clients work together to improve client-centered care.
CCP’s Heather Hancock, another author of the commentary, says that while attempts have long been made to improve provider behavior, only in the last decade or so has the term “provider behavior change” come to the fore. She says that attempts at systems-level interventions often overlooked the role of providers and some provider-based interventions left out systems-level needs. What is needed, she says, is for a better consensus on how these concepts can be joined together in a more holistic approach.
In family planning and reproductive health, provider behavior change “has often been equated with addressing provider bias or building interpersonal communication skills, which is a narrow and oversimplified conception. Those working with providers—including those in other health areas—must come together to deliberately define [provider behavior change] and discuss what is needed to support providers in advancing the practice of respectful and person-centered care across the life course,” the authors wrote in the commentary.
Adds Hancock: “It’s really understanding that providers are people. And, as people, they have so many factors at different levels of what we might call an ecosystem that influence their behavior. And, so, we really need to have empathy for providers and think more broadly about what we can do to support them by addressing factors at all levels of their ecosystem.”
Recently, the CCP-led Social and Behavior Change Activity project in Uganda used the Provider Behavior Change Toolkit developed by Breakthrough ACTION to facilitate discussions with providers about what influences their behavior and to co-design solutions that addressed those factors.
The project discovered a wide range of factors influencing provider behavior including community norms, resource availability, power dynamics, restrictive regulations and workplace culture. “Providers exist and work in complex systems and we can’t ignore those systems,” Hancock says.
In the commentary, Carlson, Hancock and their colleagues provide a list of six recommendations for improving family planning and reproductive health through advances in provider behavior change interventions, including addressing the diversity of providers and their environments, expanding programming to address the many drivers of patient behavior and combining both provider-side and client-side interventions to ensure a cohesive approach.
“Six Recommendations for Provider Behavior Change in Family Planning” was written by Hancock, Carlson, Hope Hempstone, Bethany Arnold, Kamden Hoffmann, Xaher Gul and Kathryn Spielman.
Global Health: Science and Practice is part of the USAID-sponsored, CCP-led Knowledge SUCCESS project.
This research is funded through the U.S. Agency for International Development under the Breakthrough ACTION Cooperative Agreement #AID-OAA-A-17-00017, the MOMENTUM Country & Global Leadership Cooperative Agreement #7200AA20CA00002, and the MOMENTUM Integrated Health Resilience Cooperative Agreement #7200AA20CA0005.