Applying a Power and Gender Lens to Understanding Health Care Provider Experience and Behavior: A Multicountry Qualitative Study

"As health systems sit within and reflect the values of the societies in which they are based, they can reinforce gendered values, power relations, occupational opportunities, and norms in ways that affect relationships during health care interactions..."

Healthcare providers (HCPs) in reproductive, maternal, and newborn health (RMNH) face environmental, structural, and gender-related challenges in their work, as well as inequitable societal and gender norms, that are internalised and consequently affect provider behaviours and client experience. This study investigates provider perspectives and behaviours using 4 interrelated power domains - beliefs and perceptions; practices and participation; access to assets; and structures - to explore how these constructs are differentially experienced based on one's gender, position, and function within the health system. The goal is to explore manifestations of power and gender from HCPs' perspectives and how these relational dynamics affect provider behaviours with clients and peers.

This analysis draws on 4 independent studies in sub-Saharan Africa under Breakthrough RESEARCH, a United States Agency for International Development (USAID)-supported global social and behaviour change (SBC) evidence generation project. The researchers conducted a secondary analysis of qualitative in-depth interviews (IDIs, n=123) with 3 different cadres of HCPs - community-based providers, facility-based providers, and facility-based senior providers/managers - providing RMNH services in Kenya, Malawi, Madagascar, and Togo. IDIs included information on HCPs’ experiences and perspectives on their work, work environment, and interaction with clients and the community.

Results present providers' perspectives and experiences of power dynamics - including power within, power to, power with, and power over - across 4 domains. For each domain, the researchers present key themes that highlight dynamics and distinctions by country context, HCP cadre, and/or gender:

I. Beliefs and perceptions: HCPs' power to deliver high-quality care is influenced by perceptions of relationships and interactions with clients, families, peers, and supervisors, as well as interprovider collaboration and community norms. In general, HCP perspectives reveal that clinical knowledge gave them relative power with clients. Power dynamics manifested in the communication and tone set and perceived between providers and clients during 1-on-1 service interactions. Across all countries, HCP cadre, and gender, the study found that strategies, such as listening, coaching/mentoring, and dialoguing that emphasised communication style and tone, could foster a favourable power dynamic between providers and clients. These strategies enabled positive interactions that reduced provider power over clients and elevated provider power to achieve a service goal. Data showed community members' confidence and trust in HCPs working in community and facility settings empowered them to counsel clients. All HCP cadres in all 4 countries described how a community's societal beliefs and social norms at times misaligned with medical procedures, affecting HCPs' power to provide timely care. For example, in Malawi and Togo, the religious belief that contraceptive methods were "sinful" or "against God" constrained facility- and community-based HCPs' power to provide care.

II. Practices and participation: Power with and over other providers was experienced through interprofessional collaboration in decision-making and care processes as described through norms of working together in a particular context. Kenyan, Togolese, and Malawian providers - male and female - suggested that overcoming hierarchical challenges and improving collaboration between cadres required understanding the unique value and skills each HCP brought to a care team, including their relationships with and proximity to clients/communities. Interprovider power dynamics suggest that too much HCP power over can sometimes be as consequential as a lack of power to providing quality care.

III. Access to assets: HCPs' power is constrained by limited access to resources, advancement opportunities, and supportive supervision. HCPs reflected that they and their clients were so accustomed to inadequate resources and high client volume that the resultant stress-induced poor quality of care was normalised in the community. Across countries, cadres, and gender, supervision quality and emotional support emerged as salient themes that affected providers' agency (power within), power to work with peer HCPs, and ability to interact with clients effectively. Gendered perspectives and intersections marginally emerge in this domain, where inequitable support may uniquely affect power and behaviours of female providers. In particular, nurses can be subject to gender biases in the community and facility, and they may lack sufficient support for childcare.

    

IV. Structures - institutions, laws, and policies: Power manifested in structures through the scarcity of human resources and limited policies, protections, and practice guidance, with little difference by HCP cadre or gender. HCPs across the 4 countries felt continued professional development would ensure quality care provision - irrespective of cadre and gender.

Across domains, the study shows varied patterns of how power manifests among community- and facility-based providers. For example, community-based HCPs in Togo demonstrated high power to provide services, deriving from their agency to work autonomously in community settings with programme support and trusting relationships with clients. In contrast, facility-based HCPs in Kenya, Madagascar, and Malawi providing services within teams in hierarchical professional environments experienced constraints to their power to practice. This pattern reflects normalised negative facility reputations and deference to authority (senior providers/managers) and restriction of interprofessional collaboration.

In short, the study found that an HCP's power to provide high-quality care, including counseling, drew on all 4 domains, given the range of relationships and interactions involved, including with clients, families, peers, and supervisors. HCPs' power to provide quality care drew primarily from the beliefs and perceptions domain: The more respectful, equal, and open the individual and collective interactions perceived by clients and communities, the more favourable the power dynamic to optimise care experiences. Power with and between colleagues to provide services primarily reflected the practices and participation domain - HCP relationships with other providers that gave rise to decision-making and collaboration norms in care provision - as well as the structures that formally and indirectly influenced HCPs' working contexts. The findings point to the importance of enhancing HCP power with communities, peers, and senior managers as programmatically relevant for improving the quality of care across health areas.

Implications include:

• Programme stakeholders should consider participatory mechanisms for routine community feedback (positive and negative) to improve the client-provider interaction experiences.
• Facility managers should consider team-building strategies to overcome challenging interprovider dynamics and reinforce collaboration and trust.
• Policymakers and national stakeholders should consider HCPs' power-influencing factors within provider behaviour change efforts, including allocations for equitable access to resources and supervision, provider growth opportunities, and guidance for task-sharing.
• Leveraging civil society partnerships within diffusion strategies and using culturally acceptable, health area-specific, interpersonal communication-promoting job aids within provider training and client interactions may facilitate opportunities for HCPs to realise their power in practice.

Looking ahead, the researchers recommend further investigation of the psychological underpinnings of power, the use of theoretical frameworks, critical approaches, and tools to assess power and quality of care. In addition, they suggest an ongoing focus on implementation research to evaluate power differences and dynamics in response to SBC programming.

In conclusion, "prevailing power and gender dynamics in varied relationships at the health service interface influence providers' behaviors and clients' care experiences....Unveiling these dynamics can elevate HCPs' perspectives on power-enhancing approaches to strengthen quality of care and generate more nuanced SBC programming interventions aimed at better supporting HCPs."