Research Spotlight / March 2020

The Beyond Bias Project

Building Evidence to Inform Practice for Provider Behavior Change Programming

Introduction

Advancing Social and Behavior Change (SBC) 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:

  • Gaps in existing evidence on integrated SBC/PBC programming
  • Priority research and learning questions and the consensus-driven process used to derive them
  • Roles of key stakeholders for putting the research and learning agenda into action

What Are Provider Behavior Change Interventions?

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.

Health Communication Capacity Collaborative. 2017. Provider Behavior Change Implementation Kit.

Four Key Areas of Inquiry for Advancing Provider Behavior Change Programming

Organizational characteristics and values
Effectiveness
Intervention strategies
Measurement
Breakthrough RESEARCH. 2019. “Advancing provider behavior change programming,” Research and Learning Agenda. Washington, DC: Population Council.

Applying the Research Questions to a Current PBC Project

In this research spotlight, we share key highlights from a PBC project to:
  • Demonstrate how priority RLA questions are being answered to improve PBC programming
  • Share tools and resources for other program implementation and research partners
  • Raise the visibility of current PBC technical work
Beyond Bias Project
Beyond Bias logo

What is Beyond Bias?

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.

Why focus on provider bias?

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.

What is Beyond Bias doing?

Beyond Bias is designing and testing innovative, scalable solutions that disrupt the status quo (i.e., training and supervision), which has had limited success.

What is Beyond Bias’ unique approach?

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.

What is the Beyond Bias hypothesis?

By understanding what drives provider bias, small changes can be made to shift these biases and remove provider-related barriers.

What is the project timeline?

November 2016 – March 2021

Where is the project operating?

Burkina Faso, Pakistan, and Tanzania

How did Beyond Bias bring together distinct perspectives in this project?

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.”
—Lydia Murithi, project director, Beyond Bias

What was the project’s definition of provider bias?

Provider bias was defined as a provider’s judgmental attitude or behavior toward adolescents in the provision of reproductive health services.

Why did the project focus on Burkina Faso, Pakistan, and Tanzania?

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 priority RLA questions did Beyond Bias answer and how?

Table image
Underlying Drivers

Priority PBC Question

What Are the Underlying Drivers That Shape Provider Behavior in Interpersonal Communication With Clients?

Purpose

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.

Methods

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.

It explored five sets of drivers that enable or activate provider bias toward adolescent:

  1. Social norms – Unwritten codes of conduct, values, and belief systems that are socially negotiated and understood through social interaction
  2. Situational biases – Factors that pertain specifically to a providers' care environment (e.g., workload issues, concerns about community reputations) and are present for all providers in a given clinical setting
  3. Provider-specific biases – Drivers that are inherent or unique to individual providers based on their personal histories, characteristics, education, experiences, or other identifiable personal traits
  4. Client-specific attributes – Traits that may differentially activate the specific underlying drivers of provider bias, such as sex, marital status, parity, poverty, religion, ethnic group or geographical affiliation, or specific method preferences
  5. Method-specific biases – Provider beliefs about the appropriateness of certain contraceptive methods based on its perceived effects on the physiology or impact on fertility for a youth client

Output

A searchable matrix in Excel (Summary Tool) of available evidence.

Purpose

Focus on perceptions about contraceptive use, role(s) of providers, bias influencers, and behavior change.

Participants

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.

Output

Interview summaries across five major categories:

  1. General notes and respondent background
  2. Perceptions on adolescent/young adult contraception use
  3. Perceptions on the role of providers
  4. Perspectives on bias influencers
  5. Perspectives on behavior change

Key Findings From the Literature Review and Expert Interviews

Key Finding 1

Societal or community attitudes drive most documented provider bias. The most prevalent attitudes were expectations for:

  • Young people to abstain from sexual activity before marriage
  • Young married women to bear children and prove fertility
Key Finding 2

The most consistent drivers of provider bias were:

  • Lack of understanding of youth needs and poor communication in provider-youth interactions
  • Disincentives to work with adolescents because they require more time and sensitivity
  • Incorrect guidance on side effects and fertility risks of contraception for youth, particularly for long-acting hormonal methods
  • An empathetic, protective, parental attitude can lead to discrimination against youth
  • Heavy workload and stress may exacerbate existing biases
  • Bias exists on a spectrum, and our understanding needs to consider the severity of bias and the repercussions for youth
Key Finding 3

A range of client characteristics influence interactions with providers:

  • Young clients’ appearance, maturity, age, education level, gender, and marital status can exacerbate or ameliorate the bias drivers in providers
  • Young clients prioritize confidentiality and privacy in clinical settings
  • Youth often want adult involvement in critical decisionmaking, which might violate their own general desires for privacy and independence

How Did the Beyond Bias Team Synthesize This Information?

Camber Collective. 2018. Beyond Bias: Provider Survey and Segmentation Findings: 26.

Output

Beyond Bias developed a Provider Bias Driver Tree—an exhaustive set of drivers aggregated into three distinct categories:

  1. Biases specific to providers and youth clients (biographical)
  2. Situational factors
  3. Broader social or cultural effects

These three distinct subsets of provider biases can be triggered, exacerbated, or ameliorated by specific adolescent demographic and behavioral traits.

Provider Bias Driver Tree

Provider Bias Driver Tree
Camber Collective. 2018. Beyond Bias: Provider Survey and Segmentation Findings.
Profiles of Providers

Priority PBC Question

How do the underlying drivers shape provider profiles?

Purpose

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.

Led by

Camber Collective, in collaboration with in-country market research firms.

Participants

811 providers:

  • 310 providers from Burkina Faso’s Centre Est, Centre, Cascades, and Hauts-Bassins districts
  • 200 providers in Pakistan’s Karachi district
  • 301 providers from Tanzania’s Dar es Salaam area

Methods

A quantitative survey captured demographic factors, focusing more on attitudinal and behavioral characteristics to develop empirically derived segments of provider profiles within each country.

Survey Tool

Several types of questions and data collection methods were designed to measure provider bias. These include:

  • Agree/disagree scales with statements relating to youth, sexuality, and contraceptive use
  • Questions about services provided to adolescents, including the methods, advice given, and the social and systemic factors that influence the services provided
  • Questions on community and social norms and the role that norms play in their service administration
  • A story about a fictional adolescent client followed by questions about the kinds of services and advice the provider would offer to this client

What Provider Profiles Were Developed?

Detached Professional

Well-trained, though emotionally disconnected from youth

icon of Burkina Faso

Average Passive

Aware of adolescent and youth sexual and reproductive health practices, but somewhat biased and relatively unsympathetic for youth

icons for Burkina Faso, Pakistan, Tanzania

Content Conservative

Generally open-minded and youth friendly, but distrustful of modern methods and independent women

Icon of Pakistan

Impromptu Sister

Most connected with young clients, though also prone to believe they know what’s best

icon of Burkina Faso and Tanzania

Sympathetic Guardian

Well-intentioned, and though somewhat misinformed, exhibit overall high-quality youth service

Icon of Tanzania

Paternalistic Clinician

Busy older doctors who, despite some progressive attitudes, show strong marital and parity bias

Icon of Pakistan

Purpose

For program managers, trainers, and implementers to understand their target providers and tailor their engagement.

Output

A country-specific classification tool to accurately assess which segment a provider is best aligned.

Dominant segment:

  • Detached professionals (79% of providers)

What bias looks like:

  • Prioritize older clients
  • Do not explain all methods or side effects
  • Likely to promote abstinence to unmarried youth
“I have too many patients and too little space. Sometimes women deliver on the floor because we don’t have enough tables.”
Provider, Burkina Faso

Questions from the classification tool used to identify provider’s profile and design appropriate intervention strategies in Burkina Faso:

  • Young women without children should not use any product that may cause a delay in fertility once stopped
  • I'm paid fairly for the work that I do
  • I enjoy working with young clients in general
  • A client with just one daughter will have different family planning needs than a client with just one son
  • Providing contraceptive services to youth makes me worry about my clinic's reputation in the community
  • How would you describe the economic status of the youth clients you treat in general?
  • Have you ever participated in a training that covered provision of family planning services to youth?

Beyond Bias Images

Developing Solutions

Priority PBC Question

Which Intervention(s) or Combinations of Interventions Are Most Important to Improving the Quality of Provider Counseling?

Design Research Insights

How Did the Project Identify Provider Profiles?

Beyond Bias. 2019. Beyond Bias: Design Research Report.
Murithi, Lydia, Theo Gibbs, and Bram Brooks. 2020. Tackling Provider Bias in Contraceptive Service Delivery: Lessons From the Beyond Bias Project.

Purpose

Develop a series of solutions to help minimize provider bias.

Led by

YLabs led qualitative design research in collaboration with Pathfinder International.

Participants

Providers, young people, and other health system stakeholders.

Methods

Design research methodologies including interviews, observations, roleplay, and participatory research activities to investigate provider biases and behavior toward young women.

What Were the Overarching Design Questions That Helped Kickstart Ideation?

  • How might we help providers guide informed contraceptive choice by youth?
  • How might we support providers to have the time and space to honor young people’s needs in the clinic?
  • How might we measure and reward quality service for youth?

Output

More than 100 ideas were generated by all partners.

Beyond Bias. 2019. Beyond Bias: Design Research Report
Murithi, Lydia, Theo Gibbs, and Bram Brooks. 2020. Tackling Provider Bias in Contraceptive Service Delivery: Lessons From the Beyond Bias Project.

Purpose

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:

  • Develop a clear understanding of which solution concepts are desirable to our users (providers and/or youth clients) and why
  • Identify the changes that need to be made to the prototypes to improve their desirability and impact on reducing provider bias
  • Generate new ideas, if necessary, that better meet user needs and better target the drivers of provider bias in the target country context

Led by

Ylabs, in collaboration with Pathfinder International.

Participants

97 healthcare providers and 22 youth (and a few mothers-in-law) in Burkina Faso, Pakistan, and Tanzania.

Methods

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.

How Did Beyond Bias Refine Potential Intervention Solutions to Identify One Intervention?

Purpose

Conducted live prototyping to rapidly design, test, and refine potential interventions.

Led by

YLabs and Pathfinder International.

Method

Potential solutions were assessed and advanced based on the following core criteria, centered around solutions that could be taken to scale:

  • Does the solution have the potential to scale?
  • Is it desirable to users?
  • It is acceptable to gatekeeper stakeholders?
  • Does it have potential for impact?
  • Is the solution feasible to implement?
Murithi, Lydia, Theo Gibbs, and Bram Brooks. 2020. Tackling Provider Bias in Contraceptive Service Delivery: Lessons From the Beyond Bias Project.

What Was the Final Solution Design?

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.

Phase
Phase
Activate
Pre-Contemplation Contemplation Determination
Phase
Apply
Action Relapse
Phase
Achieve
Relapse
Experience

Summit

Connect

Rewards

Behavior Change Mechanism
  • Humanize bias and hold up a mirror to providers
  • Improve emotional connectivity with youth
  • Address providers’ fears of community backlash
  • Address concerns about fertility delays
  • Educate around safety of methods for youth
  • Activate contextualized agency
  • Create accountability for service quality
  • Offer visible, performance-based rewards
  • Shift professional norms
Outcomes
  • Sensitive communication
  • Safe, welcoming space
  • Seek understanding and agreement
  • Security of information
  • Say yes to a safe method
  • Simple, comprehensive counseling

Output

A three-part, adaptive solution to address provider bias.

Summit

Story-driven event with providers to:

  • Identify and recognize their own biases and train them on unbiased care
  • Identify what was feasible for the intervention given time constraints
“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.”
—Provider, Tanzania, after experiencing the Summit prototype event

Connect

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.”
—Provider, Pakistan, after engaging the Connect prototype forum on WhatsApp

Rewards

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.”
—Provider, Tanzania, after experiencing the Rewards prototype program

What Are the Plans for Implementation?

Currently underway

Purpose

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.

Led by

Pathfinder International

Participants

227 facilities across all three countries

What Are the Plans for Evaluation?

Fall 2020

Purpose

Evaluate the impact of the intervention program on provider behavior.

Led by

BERI

Participants

A mixed-methods randomized control trial to assess changes in provider bias, contraceptive use, and sexual and reproductive health services.

For More Information

For more information about Beyond Bias, please contact Lydia Murithi, lmurithi@pathfinder.org or visit the Beyond Bias project.

For more information about Breakthrough RESEARCH visit the Breakthrough RESEARCH project.

Acknowledgements

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.

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