Interventions that aim to ensure and increase quality service delivery require behavior change plans designed to meet the needs of health care providers.
There are three broad categories of factors that influence provider behavior:
- Opportunity – providers have sufficient resources and a supporting environment
- Ability – providers have the required skills and knowledge to provide quality services, and understand the performance expected.
- Motivation – providers are sufficiently motivated.
These four factors act across various levels of the ecosystem within which the health provider lives and works. Opportunity factors, such as supportive guidelines and policies or a consistent supply of commodities, could be addressed at the health systems or organization level. Likewise, motivational factors, such as adequate pay or supportive norms, might be addressed at the organization or community levels, respectively.
It can be challenging, however, to address motivational factors at the provider level because these involve issues intrinsic to the person, such as personal values and attitudes. The usual interventions here (e.g., trainings, supportive supervision, etc.), are better suited for addressing ability factors, not necessarily motivational ones. To influence motivation, PSI uses provider behavior change communication (PBCC).
PBCC takes place during ongoing and regular one-to-one conversations with providers. During these conversations, trained PSI staff use PBCC techniques to identify individual motivators and barriers to performing the desired behavior and provide solutions to address them. PBCC can be used in conjunction with classroom and field-based trainings.
PSI’s PBCC approach is modeled on medical detailing – the most effective marketing tool employed by the private sector pharmaceutical industry to influence provider behaviors. PSI’s PBCC approach was co-designed with one of the largest pharmaceutical companies in the world and based on their proven best practices.
PSI builds capacity in PBCC among its network members through our PBCC Associate Program. This program takes field staff from network member offices, trains them for more than a month on PBCC and program design and assessment, and then sends them to another network member for five months of long term technical assistance. The result is a team of in-country PBCC specialists as well as a “backbench” of PBCC experts who can deliver technical assistance throughout the PSI network.
PSI segments and prioritizes providers to maximize efficiency. Segmentation is based upon two factors. The first is the provider’s potential health impact, which considers such things as the burden of disease in the provider’s catchment area and client volume. The second factor is the degree to which the provider has adopted the promoted behavior. PSI is also experimenting with tele-detailing, which supplements the face-to-face visits with telephone or other electronic-based interactions, reducing overall costs.
Rapid prototyping and continuous feedback loops are designed to refine messages that allow PBCC interventions to be nimble. These adapt quickly to the needs of providers and their clients without the need for traditional, and often cumbersome, formative surveys so that scale and impact can be quickly maximized. Instead, PBCC agents develop personalized plans for each provider that address specific barriers, moving her or him along a behavior change continuum towards the desired behavior.
PSI’s PBCC programs produce results. At Population Services Khmer (PSK), PSI’s local implementing partner in Cambodia, the use of PPBC techniques by medical representatives helped them to positively influence the quality of counseling provided by pharmacists to their clients on short-acting family planning methods.
More than 25 PSI countries use PBCC to change provider behaviors in the areas of reproductive health, malaria control, HIV prevention and treatment, and youth friendly services.
Making a Difference
Tears Wenzira, is an unlikely health worker. A hairdresser by trade, Tears also teaches her clients about female condoms, explaining their benefits and how to use them. Tears sells about 100 female condoms per month, making enough extra money to buy basics like bread and milk for her family. She is one of more than 2,000 hairdressers in Zimbabwe who work on the PSI/Zimbabwe HIV prevention program, co-funded by the United States Agency for International Development (USAID) and the U.K. Department for International Development.
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PSI Somaliland is currently implementing a DFID sponsored SAHAN (Somali Advocates for Health and Nutrition) program, applying HCD (Human Centered Design) to develop innovative behavior change interventions aimed at increasing utilization of maternal health services.
- Influencing Behaviour Change for Increased AYSRH Service Uptake Among Ugandan Youth Using Human Centered Design
- “Stigma And Discrimination-Free Zones”: An Innovative Approach to Engaging the Private and Public Sectors in Creating More Inclusive Environments for Key Populations in Central America (TUPED509)
Central America's HIV epidemic is concentrated in key populations (KPs). Despite existing HIV laws and policies that respond to KP's specific needs, there is evidence of widespread discriminatory attitudes and practices towards these populations, and stigma and discrimination continue to be important barriers to accessing HIV services and care. In 2016, under the USAID Combination Prevention Program for HIV in Central America, PASMO designed an intervention entitled “stigma and discrimination-free zones” as part of a broader initiative known as Generation Zero, contributing to the goal of “getting to zero discrimination.”
- HIV Care is Fine, But What if I Get the Flu? (THPED546)
In Guatemala, a concentrated epidemic within a highly stigmatizing social context creates an environment fraught with challenges for reaching, testing, and linking vulnerable men who have sex with men (MSM) and transgender women (TW) with HIV testing and care. PASMO commissioned an ethnographic study in 2016-2017 to understand the sexuality, identity construction, health care seeking behaviors, and MSM/TW-health provider relationships to design consumer-focused strategies to facilitate access to HIV services.
- Sexual Practices of Men Who Have Sex with Men (MSM) in Madagascar (WEPED432)
MSM are a vulnerable population with a high prevalence of HIV (14.8%) and low HIV testing coverage (16.5%) in Madagascar. This study aims to examine barriers and motivation to HIV prevention, specifically on HIV testing, and condom and lubricant use among MSM in order to refine behavior change communication and programmatic strategies.
- Mapping Population Sizes and Hotspot Locations for Female Sex Workers Improved Targeting for HIV Prevention Interventions in Ethiopia (TUPEE702)
HIV prevalence among female sex workers (FSWs) in Ethiopia is approximately 23%. To address risk of HIV in this population, the MULU/MARPs combination HIV prevention project was launched in 2012 across 168 Ethiopian towns/cities. Implementation was challenged by insufficient data on FSW locations and sizes. A rapid size estimation approach was developed to aid program implementation.