Effectiveness of provider behavior change approaches for improving family planning services in Ouagadougou Partnership countries: A landscaping review

Summary:

Effective client-provider interactions are essential to consistent demand and uptake of family planning services. The quality of a client-provider interaction can be influenced by a provider's knowledge, attitudes, biases, and expectations, as well as structural factors such as method availability or privacy of counseling space. Several studies found that provider bias can influence the types of products and services offered to young married and unmarried women, which can result in limited access to health services. Despite the importance of a provider's role in influencing clients' use of contraception, little is known about which interventions are most effective, particularly in the Ouagadougou Partnership (OP) countries. USAID's Breakthrough RESEARCH project conducted a landscaping review to explore provider behavior change (PBC) approaches for improving family planning (FP) service utilization in the OP countries. The review involved a synthesis of grey and published literature, with additional information from key informant interviews with select projects that are testing PBC approaches at present. Despite the fact that provider bias is shown to be associated with client outcomes, only one study examined interventions to address provider bias in the OP countries. Ongoing evaluations that will be completed in the next five years will inform future programs aimed at improving client-provider interactions. In addition, findings from the landscaping review suggest that future programs should consider focusing on documenting the interventions' underlying theory of change, as well as early lessons learned from prototyping and formative work, in order to strengthen the evidence base in this area.

Background/Objectives:

Effective client-provider interactions are essential to consistent demand and uptake of family planning services. The quality of a client-provider interaction can be influenced by a provider's knowledge, attitudes, biases, and expectations, as well as structural factors such as method availability or privacy of counseling space. USAID's Breakthrough RESEARCH project conducted a landscaping review to explore provider behavior change (PBC) approaches for improving family planning (FP) services in the Ouagadougou Partnership countries (OP). The objective of this presentation is to summarize findings from the review, highlight gaps in evidence and identify areas for future programmatic and research investments.

Description of Intervention and/or Methods/Design:

The landscaping review focused on the OP countries and included interviews with key informants and a literature search. We conducted interviews from August through September 2019 and interviewed representatives from three organizations working on PBC. We requested information on the nature, scope and, where possible, the impact of the PBC interventions. We complemented these interviews with a literature search. We searched Pubmed (from 2000 to present) for peer-reviewed literature and the USAID Development Experience Clearinghouse, conference websites including the International Conference on Family Planning and the Sommet Francophone pour le Changement Social et de Comportement, and PBC implementing partner websites for grey literature. We focused the search on interventions that included a component aimed at providers and categorized the interventions by type of approach during screening. We created matrices capturing key details on geographic location, key outcomes and approach to facilitate comparisons across studies.

Results/Lessons Learned:

Studies were limited in geographic scope, with most in Senegal, Guinea, Mali and Niger. There were gaps in approaches used and barriers addressed. The most common approaches used were managerial and training or education. Only one review explicitly targeted provider attitudes/biases as part of provider training. Although the studies generally found positive effects, sustainability of improvements was not assessed. Only one collected data on cost. Most did not assess the impact of PBC interventions on provider-level outcomes, including knowledge or attitudes. Studies more often assessed client FP uptake, a more distal outcome, and most did so using routinely collected data. There is a need to assess provider-level outcomes to validate theories of change and ensure expected outcomes among providers are achieved. Despite gaps in the documented evidence, there are many ongoing PBC studies in OP countries that may address these questions in the next few years.

Discussion/Implications for the Field:

Previous studies have found that provider knowledge, attitudes, and biases influence service utilization. PBC interventions offer promising approaches to address these barriers. However, there is limited evidence on effective approaches in OP countries. Ongoing evaluations due to finish in the next five years will inform future programs aimed at improving client-provider interactions. Findings from the landscaping review suggest that future programs should consider focusing on addressing attitudinal barriers such as bias, documenting theories of change and early lessons learned from formative work, assessing outcomes at the provider level, collecting cost data, and evaluating sustainability to strengthen the evidence base.

Abstract submitted by:
Leanne Dougherty - Population Council
Kathryn Spielman - Population Council 
Elizabeth Tobey - Population Council 
Martha Silva - Population Council