The Case for Using a Behavior Change Model to Design Interventions to Promote Respectful Maternal Care

"Leveraging existing frameworks to promote behavior change can help facilitate action toward improving RMC in Africa and globally.

At the core of respectful maternal/maternity care (RMC) is a woman's experience, much of which is determined by the interpersonal interactions with those providing her care - in other words, a set of behaviours of the providers. These behaviours are influenced by facility characteristics and the system with which she interacts, including the culture. Grounded in the belief that viewing RMC interventions through a behaviour change lens can support a systematic approach, this article provides an example of how RMC interventions could be informed by an implementation science framework using the COM-B model (capability-opportunity-motivation that leads to behaviour change) and related behaviour change wheel (BCW).

The COM-B model (see Figure 1, just below) is at the centre of the BCW framework (see Figure 2, further below); together, they help identify barriers and enablers to a targeted behaviour - in this case, RMC. The researchers argue that COM-B and the BCW may be useful not only for understanding the challenges that need to be addressed but also for designing the intervention itself.

In a 2022 landscaping review, the researchers identified 43 interventions implemented across Africa promoting RMC between 2009 and 2020, of which 16 were unique. This article leverages the same set of articles to consider if and how programmes are using implementation science frameworks, especially the COM-B model, to design and evaluate RMC interventions. In short, a few articles mentioned behaviour change broadly (though not all). Only 1 article specifically mentioned behaviour change and implementation science.

The researchers undertook a mapping exercise; Figure 2 shows the distribution of the 16 unique interventions and their focus of action.

Although most interventions used multiple strategies at multiple levels, core to many interventions were community-level awareness-raising efforts, such as educating providers and community members about RMC (psychological capability) and addressing beliefs and norms (reflective motivation and social opportunity). Interventions such as social accountability and community engagement may be more challenging to implement than other types.

Among the takeaways from the analysis is that "supporting providers to enable them to act upon the knowledge gained is essential and requires activities at multiple levels. For example, changing norms, such as around accepting women's agency to advocate for the care she desires and other gender norms, at the community level and engaging supervisors at the facility level may create the enabling environment needed for lasting provider behavior change."

In conclusion: "By applying a behavior change framework, such as the COM-B model to RMC interventions, implementers have a tool to help them frame their approaches to target behavior change effectively. The model helps tease out the factors contributing to the complexity of provider/patient interactions and encourages implementers to consider a multidomain approach that cuts across motivation, opportunity, and capability. The framework also provides an approach to guide indicator selection and monitoring for the evaluation of impact."