Evidence Review and Analysis of Provider Behavior Change Opportunities

"This [behavioural economics] approach entails identifying contextual features that affect how individuals make relevant decisions and take action, and then designing solutions that can change this context or mitigate the impact of contextual barriers to improve health within existing practical constraints."

Providers' communication and interaction with patients can have a profound influence on patients' care-seeking and self-care behaviours. Just as patients may act in ways that do not align with their health intentions, providers may also act sub-optimally in ways that affect patient health. Research from behavioural economics is a tool for strengthening programming by providing a lens for understanding behaviour, including providers' behaviour. This paper reviews the potential for provider behaviour change interventions through provider-facing interventions in five health areas that are particularly critical in Zambia: family planning; maternal, newborn, and child health; child nutrition; malaria; and HIV/AIDS. The analysis suggests where and how behavioural economics interventions may be impactful and where further research may help build the knowledge base in various contexts around the world.

For each of 27 provider behaviours, the authors review the evidence on three questions:

1. What is the potential link between this provider behaviour and health outcomes?
2. What interventions (behavioural and otherwise) have attempted to improve this provider behaviour, and what is the evidence of their effectiveness?
3. To what extent are the challenges driven by behavioural, rather than structural (i.e., infrastructure or clinical skills), factors?

Here is an example:

• Example behaviour: Provider encourages full completion of timely vaccinations for children under two years old.
• Potential link between provider behaviour and health outcomes: Factors over which providers may exert influence include demand generation, convenient and predictably available vaccination sessions, practical counseling about why to get vaccinated and about expectations post-vaccine, and provider attitude toward patients. Providers can also reduce fear and hesitancy by addressing reports of serious adverse events following immunisation.
• Interventions focused on this behaviour: For example, ideas42 has developed interventions for health providers in Ethiopia including behaviourally informed tracking posters that display the immunisation status of providers' patients, allowing them to survey which babies are behind schedule, as well as display and take pride in their successful immunisations. In addition, providers receive text message reminders prompting them to reference the poster and perform outreach to those who drop out prior to immunisation campaigns.
• Potential application of behavioural economics approaches: For example, community-based providers who play an active role in identifying newborns for immunisation may influence a caregiver's decision to get the initial immunisation or spur action by helping her develop a concrete plan to attend an immunisation session.
• Conclusion from the analysis: Behavioural economics approaches may hold promise for improving immunisation coverage through this provider behaviour: (i) when there are well-organised efforts to promote immunisations through community-based providers, and structural barriers for accessing immunisation are surmountable; (ii) there are high rates of facility-based delivery or postnatal care, or (iii) where immunisation initiation rates are high but follow-through on subsequent vaccines is low.

Cross-cutting insights and applications include:

• Behavioural barriers arise from features of the context in which providers live and work that trigger universal psychological tendencies. Thus, understanding how cues in one context contribute to a behavioural barrier can generate insights into how a similar barrier might arise elsewhere for a different provider or behaviour.
• Transversal themes describe how multiple behavioural barriers might manifest into a broader area of interest, such as providers' response to a new technology or guideline. An understanding of when and how transversal themes result from behavioural barriers opens the door to applying components of one solution to another health issue or behaviour.
• Spillover effects consider ways in which the immediate effects of one behaviour may increase the likelihood of future interactions with the health system in a way that could affect other health outcomes by directly or indirectly surmounting patient-side barriers. Understanding the spillover effects of provider behaviours can eventually help move toward more comprehensive solutions.

The aim is for insights from this review to be used to inform two types of interconnected decisions about programming and research on provider behaviour change:

• Designing and adapting programmes to maximise impact, adapting proven solutions to new contexts, employing lessons from the literature to address different challenges, and making strategic decisions about where and how to intervene.
• Shaping the research agenda to fill critical gaps in understanding provider behaviour so that the impact of provider-facing behavioural interventions continues to grow.

ideas42 used the insights generated through this review to select a focus area for formative research on provider behaviour change in Zambia around best practices during facility-based delivery. This research, conducted through the Breakthrough RESEARCH project, entails using ideas42's behavioural mapping methodology combined with qualitative fieldwork to refine and validate hypotheses about the relevant behavioural barriers at play. This research will inform design of a solution to improve provider behaviour.