Building Evidence to Inform Practice for Provider Behavior Change Programming
Breakthrough RESEARCH, with input from the United States Agency for International Development (USAID) and cross-sectoral implementing partners, developed research and learning agendas (RLAs) to strengthen two important areas of social and behavior change (SBC) programming: integrated SBC programming and provider behavior change (PBC).
The RLAs identify and document:
Provider behavior change (PBC) interventions go beyond clinical training to address provider attitudes, abilities, expectations, and resources available within their environment. They seek to positively influence provider behavior to improve the quality of services, enhance client experiences, increase demand for services, and increase uptake of commodities or adoption of healthier behaviors.
Beyond Bias is a project that seeks to address provider bias by ensuring young people have access to empathetic, nonjudgmental, quality counseling and provision of a full range of contraceptive methods regardless of their marital status or parity.
Multiple barriers prevent a young person from accessing a safe method of contraception of their choice. Provider bias occurs at the last meter of care—the moment of consultation between youth and provider.
Beyond Bias is designing and testing innovative, scalable solutions that disrupt the status quo (i.e., training and supervision), which has had limited success.
A multidisciplinary approach that brings together experts in adolescent sexual and reproductive health (SRH), social and behavior change communication (SBCC), human-centered design, behavioral economics, and market segmentation to address this complex SRH problem.
By understanding what drives provider bias, small changes can be made to shift these biases and remove provider-related barriers.
Led by Pathfinder International, in collaboration with Camber Collective, YLabs, and the Behavioral Economics in Reproductive Health Initiative (BERI), with funding from the Bill & Melinda Gates Foundation.
November 2016 – March 2021
Burkina Faso, Pakistan, and Tanzania
With a mandate to disrupt the status quo, the project needed to assemble a multidisciplinary team to generate new solutions. Team members from different disciplines (e.g., social and behavior change communication, human-centered design) brought their own way of thinking.
The Beyond Bias team had to come together with intellectual empathy and humility to move beyond each discipline’s typical way of thinking and problem solving. This multidisciplinary process required frequent, intense engagement and collaboration across the project partners at key stages during the project lifecycle.
“Pathfinder put together a team that brings different perspectives to spark innovation. The innovation is the methodology and approach based on who was brought to the table.”
Provider bias was defined as a provider’s judgmental attitude or behavior toward adolescents in the provision of reproductive health services.
In different contexts, provider bias is driven by different things (e.g., sexual activity, age). Beyond Bias sought to look for key underlying drivers that are shared globally, allowing the project to develop solutions that can be adopted in multiple contexts.
What Are the Underlying Drivers That Shape Provider Behavior in Interpersonal Communication With Clients?
Synthesize what is currently known about healthcare provider bias; identify key factors likely to drive provider bias; identify gaps in the research/evidence base; and identify previously used quantitative measures of provider bias.
The literature review used the PRISMA—Preferred Reporting Items for Systematic Reviews and Meta-Analyses—checklist to outline specific steps and features of systematic reviews, and searched Google Scholar, PubMed, and PsychINFO databases.
A searchable matrix in Excel (Summary Tool) of available evidence.
Focus on perceptions about contraceptive use, role(s) of providers, bias influencers, and behavior change.
Twenty-nine expert informants were identified and contacted for semi-structured interviews. Experts included adolescent medical providers, global experts in sexual and reproductive health, academic researchers and thought leaders on adolescent development, and behavior change experts.
Interview summaries across five major categories:
Societal or community attitudes drive most documented provider bias. The most prevalent attitudes were expectations for:
The most consistent drivers of provider bias were:
A range of client characteristics influence interactions with providers:
Beyond Bias developed a Provider Bias Driver Tree—an exhaustive set of drivers aggregated into three distinct categories:
These three distinct subsets of provider biases can be triggered, exacerbated, or ameliorated by specific adolescent demographic and behavioral traits.
How do the underlying drivers shape provider profiles?
Investigate the relative influence of different types of bias for each provider so that the data can be analyzed to identify the most prevalent influencers and types of bias for different segments of the provider population.
Camber Collective, in collaboration with in-country market research firms.
A quantitative survey captured demographic factors, focusing more on attitudinal and behavioral characteristics to develop empirically derived segments of provider profiles within each country.
Several types of questions and data collection methods were designed to measure provider bias. These include:
Well-trained, though emotionally disconnected from youth
Aware of adolescent and youth sexual and reproductive health practices, but somewhat biased and relatively unsympathetic for youth
Generally open-minded and youth friendly, but distrustful of modern methods and independent women
Most connected with young clients, though also prone to believe they know what’s best
Well-intentioned, and though somewhat misinformed, exhibit overall high-quality youth service
Busy older doctors who, despite some progressive attitudes, show strong marital and parity bias
For program managers, trainers, and implementers to understand their target providers and tailor their engagement.
A country-specific classification tool to accurately assess which segment a provider is best aligned.
Manifestation of Bias in Burkina Faso
“I have too many patients and too little space. Sometimes women deliver on the floor because we don’t have enough tables.”
Seven concepts were tested in rough prototyping. Photo credit: YLabs
More than 100 ideas were generated by partners during the development process. Photo credit: YLabs
Providers at a Beyond Bias event. Photo credit: YLabs
Examples of final implementation assets. Photo credit: YLabs
Refined concepts were tested in live prototyping. Photo credit: YLabs
Which Intervention(s) or Combinations of Interventions Are Most Important to Improving the Quality of Provider Counseling?
How Did the Project Identify Provider Profiles?
Develop a series of solutions to help minimize provider bias.
YLabs led qualitative design research in collaboration with Pathfinder International.
Providers, young people, and other health system stakeholders.
Design research methodologies including interviews, observations, roleplay, and participatory research activities to investigate provider biases and behavior toward young women.
More than 100 ideas were generated by all partners.
Conduct rough prototyping sessions to fail early and learn directly from users to foster rapid iteration of identified solution concepts.
The key goals of rough prototyping are to:
Ylabs, in collaboration with Pathfinder International.
97 healthcare providers and 22 youth (and a few mothers-in-law) in Burkina Faso, Pakistan, and Tanzania.
Through rough prototyping—a method in the human-centered design process—a small number of essential questions about desirability and feasibility were tested for each solution concept.
Conducted live prototyping to rapidly design, test, and refine potential interventions.
YLabs and Pathfinder International.
Potential solutions were assessed and advanced based on the following core criteria, centered around solutions that could be taken to scale:
Beyond Bias designed a three-part behavior change strategy intervention for providers with six intended outcomes that address provider bias toward adolescent sexual and reproductive health.
A three-part, adaptive solution to address provider bias.
Story-driven event with providers to:
“It’s true that there may be gaps in training, but the problem really lies within. Today I came to understand that sometimes my services to youth can be changed by my own bias.”
Built a professional community—connecting providers to one another—through a multiweek program of texts, videos, and information over WhatsApp, with a new theme each week.
“We felt like a family. It is a safe space where we can freely express whatever we think. Even our life stories were shared on the forum. I didn’t fear that someone will criticize or reprimand me. Through Connect I learned many new things. I felt valued on Connect.”
Used social reinforcement for progress as an incentive for providers. Facilities received report cards with performance data and recommendations for improvement. High-improvement facilities received public recognition for their progress.
“I changed my perspective and attitude towards young clients. My priority is serving youth just after the moment I knew my efforts would be recognized.”
Implement final solutions across all three countries, documenting experiences to contribute to the evidence on how to successfully implement multidisciplinary approaches within sexual and reproductive health.
227 facilities across all three countries
Evaluate the impact of the intervention program on provider behavior.
A mixed-methods randomized control trial to assess changes in provider bias, contraceptive use, and sexual and reproductive health services.
For more information about Breakthrough RESEARCH visit the Breakthrough RESEARCH project.
This Beyond Bias case study was developed by Sanyukta Mathur and Krista Granger, Population Council, with input from Kamden Hoffmann, Population Council, and Rachel Yavinsky, Population Reference Bureau (PRB). It was designed by ProGraphics in consultation with Nancy Andrews, Creative Director at PRB, and edited by Nancy Matuszak, PRB.
The case study was developed with the assistance of Pathfinder International and the Beyond Bias project. Thank you to Lydia Murithi, Beyond Bias project director, and Marta Pirzadeh, Senior Technical Advisor, AYSRHR, Pathfinder International, for their guidance and critical input.
This website is made possible by the support of the American people through the United States Agency for International Development (USAID). The Breakthrough awards are supported by USAID’s Office of Population and Reproductive Health, Bureau for Global Health, under Cooperative Agreements: #AID-OAA-A-17-00017 and #AID-OAA-A-17-00018. Breakthrough ACTION is based at the Johns Hopkins Bloomberg School of Public Health’s Center for Communication Programs. Breakthrough RESEARCH is based at Population Council. The contents of this website are the sole responsibility of Breakthrough ACTION and Breakthrough RESEARCH. The information provided on this website is not official U.S. Government information and does not necessarily represent the views or positions of USAID, the United States Government, Johns Hopkins University, or Population Council. All rights reserved.