Six Recommendations for Provider Behavior Change in Family Planning

"FP/RH provider behavior heavily influences the quality of health services and a client's experience of care."

Provider behaviour change (PBC) initiatives recognise the power of healthcare provider behaviour to influence family planning and reproductive health (FP/RH) outcomes, both positively and negatively. PBC interventions frequently reflect a tendency, common across public health, to address the proximate factors that influence behaviour rather than underlying social and structural factors. Informed by a narrative review of more than 70 articles and project materials, this commentary seeks to contribute to a common understanding of PBC among global health practitioners, including a common frame of reference for identifying determinants of provider behaviour, and proposes recommendations to strengthen FP/RH PBC approaches by addressing the holistic set of factors driving provider behaviours.

To build a shared understanding of PBC concepts and priorities, the commentary begins by outlining the basics: who is a health care provider; what is provider behaviour, and what factors drive it; and what are PBC interventions. Building from this understanding, the researchers propose the following recommendations to advance FP/RH PBC programming:

1. Address diversity of providers and their environments: Although facility-based doctors, nurses, and midwives are important, they are but a few of the many cadres that influence client outcomes. Global health practitioners must address a broader set of providers, including auxiliary and informal cadres, and seek to better understand their unique needs and perspectives. Building on that understanding, practitioners need to identify and prioritise the specific provider behaviours they are seeking to change, ensuring the behaviors are cadre and context appropriate. Equally important is understanding and tackling power dynamics within a facility, which can hamper PBC. Research suggests that interventions that bring together all facility staff or multiple cadres of providers and facility support personnel may be especially effective in improving inter-cadre trust and teamwork, increasing provider satisfaction and motivation, and, thus, changing behaviour.
2. Expand programming to address diverse drivers of provider behaviour: Global health practitioners must adopt a systems approach, especially in areas with historic gaps at the interpersonal, social, and structural levels. For example, at the structural level, studies emphasise the need to ensure more supportive policies and guidelines for both providers and clients. And at the social level, initiatives must acknowledge the strong influence that sociocultural norms, community-level factors, and gender norms - with associated sanctions and stigma - have on providers, clients, and the health system. Using a theory-driven approach can help implementers map and address key determinants of provider behaviour in a clearly defined pathway of change.
3. Combine provider- and client-side interventions: Despite evidence that client factors influence provider behaviour, clients are rarely a focus of PBC activities. Yet PBC interventions may benefit, for example, from activities seeking to shift client attitudes, bolster self-efficacy, and foster empathy between clients and providers. Given the dyadic nature of provider-client interaction, global health practitioners implementing PBC activities should pair provider-focused interventions with client-focused interventions. The paper article provides an example of one such intervention, the Quality Improvement Initiative in Indonesia.
4. Shift from blaming to supportive problem-solving: Efforts to improve quality of care should emphasise collective problem-solving and accountability rather than deficiencies. Empowering providers to identify and overcome barriers may require advocacy for changes to policies and procedures that influence access, opportunities, and the larger culture.
5. Move beyond training-only approaches: PBC interventions can extend learning and application if training, which should couple instructional learning with more interactive approaches, is complemented by broader efforts, such as those that work toward demand creation, client empowerment, and community support for quality services.
6. Improve the rigor of PBC measurement, and expand the evidence base: Global health practitioners should prioritise and budget for the monitoring, evaluation, and documentation of PBC activities in order to understand which PBC strategies work, in what sequence, and in which contexts. Specifically, more insight is needed into what client-side strategies might prompt improvements in provider behaviour and effective strategies for including communities as partners in PBC. Breakthrough ACTION is compiling a list of PBC indicators for measurement at each level of the Provider Behavior Ecosystem and synthesising guidance for measuring provider behaviour.

The following areas demand further exploration and collaboration between global health practitioners, as outlined here:

• Define provider behaviours, and deepen appreciation of its influences.
• Understand the needs of and synthesise recommendations for a broader group of providers.
• Understand what PBC strategies work in which contexts and for which cadres.
• Align on what constitutes PBC.
• Understand gender's role in PBC efforts between providers and clients and among providers.

The commentary concludes by stressing the need for engagement on the part of academic institutions, professional groups, normative bodies, and government structures at the national level when it comes to fostering large-scale, sustained improvements in provider behaviour. "Cultivating partnerships between government decision-makers, activists, communities, researchers, the media, medical professionals, and other key stakeholders can draw attention to the relationship between provider behavior, client satisfaction and utilization of services, and health outcomes, as well as garner support for localized PBC interventions."