Leveraging Connections Between Client and Provider Behavior: Behavioral Design for Provider Behavior Change in Care-Seeking for Children in Zambia

"This work is an example of how provider behavior change may be a relevant approach for activities that have previously been considered under the purview of health system strengthening- or client-focused interventions."



Caregivers of children experiencing symptoms of illness do not always proactively seek care or follow through on referrals to a health facility. The problem of delayed care-seeking by caregivers may, on its surface, appear to be a client-side problem. However, research conducted by Breakthrough ACTION in Zambia suggests that caregivers' care-seeking behaviour is influenced by providers' behaviour, which shapes caregivers' expectations for quality and experience of care. This brief describes lessons learned from a Zambian project that applied a behavioural design approach to better understand contextual features - the features in the environment in which providers are making decisions - and their interplay with behavioural barriers that prevent providers from providing quality care.



Behavioural design is an approach that leverages insights from behavioural economics, social psychology, human-centred design, and other disciplines to develop and test solutions that reshape people's environment to positively influence their behaviour. As part of Breakthrough ACTION, ideas42 employs a 4-stage behavioural design methodology that is outlined in the brief and that consists of:

1. Defining the problem: The team conducted in-depth interviews with health providers, community health workers, and mothers of children under five, learning that providers often scold or shout at clients. As a result of these findings, Breakthrough ACTION developed the following behavioural problem statement: "Providers do not always follow quality of care standards, including providing respectful care, when treating childhood illness, which contributes to lack of timely care-seeking by caregivers of children experiencing symptoms of illness."
2. Diagnosing the behavioural drivers of that problem: Through additional field work, the project discovered that:
   • Providers believe they are already delivering high-quality care by following treatment protocols. Supervision, mentorship, and coaching activities focus on clinical competencies and do not provide a model of respectful care, and providers may scold, reprimand, and fail to answer questions or provide explanations, since they have seen others take these actions.
   • Providers expect to be judged on clinical outcomes alone. They often exhibit outcome bias; as long as a child recovers from their illness, the provider considers the interaction to be appropriate, even if care could have been more respectful. Furthermore, provider evaluation systems prioritise the number of clients a provider visits, rather than the quality of their care. Thus, even when providers are aware of longer-term benefits, they may demonstrate present bias; the immediate costs in terms of additional time and effort required to provide respectful care strongly influence their choices at the expense of a larger, long-term benefit.
   • Providers react automatically to emotional triggers. If providers perceive caregivers' behaviour as rude in moments when their time and attention is stretched, providers may scold or mistreat clients even when they intend to treat them respectfully. Furthermore, when reacting to caregivers' behaviour, providers do not always consider the external stressors that may be prompting a caregiver to act the way they do; this is an example of the fundamental attribution error.
3. Designing solutions that address the behavioural drivers: The solutions outlined below aim to address these barriers by building empathy between caregivers and providers, clarifying the underlying shared interests and goals of both parties, and making the desired behaviours of each group explicit. In brief, the solutions include:
   • Co-creation of quality-of-care guidelines: A collaborative community-provider workshop is held to co-create common quality of care guidelines, led by a trained neutral facilitator. The guideline creation focuses on fostering an equitable environment for all involved parties and building empathy between providers and community members.
   • Client feedback system: Clients are asked to evaluate their experience after a facility visit. The facility supervisor then tabulates the feedback and shares results during regular staff meetings.
   • Provider self-assessment and goal setting: During facility discussions, providers set facility goals to improve service provision and review progress against prior goals. Through a guided self-reflection, providers have the opportunity and tools to critically assess their own performance in relation to the co-created guidelines and the client feedback they have received. Providers then set goals and plans for how to act when they are in a stressful situation, so they are prepared to remain calm the next time similar stressors arise. While providers expect to be assessed based on clinical outcomes, the self-assessment and goal setting activity increases the salience of the co-created guidelines and respectful care in their evaluation.
4. Testing the effectiveness of solutions and adapting as needed: The solutions were developed and tested with users, including providers, community members, and caregivers of children under five, to elicit feedback and make improvements prior to implementation launch. According to Breakthrough ACTION, community members were enthusiastic about the collaborative workshop since they felt they had few other outlets to set expectations with providers. Providers were able to hear community members' concerns and to share best practices for care-seeking with caregivers. Following user-testing, the designs were finalised and piloted in two districts in Zambia in early 2020. It was expected that further learnings on implementation wuld be integrated into the design package prior to scaling to all project-supported health facilities.

Selected behavioural insights relevant to provider behaviour change that emerged from this experience include:

• The environment in which providers work and the resultant feelings of scarcity and tunnel vision can have critical implications for providers' decision-making and ability to follow through on intentions. Often, these challenging environments can exacerbate the effects of other behavioural barriers.
• Risk aversion is an issue to pay attention to: Providers acted in a way that they perceived to minimise the risk of the particularly salient health consequences of delayed care-seeking.
• Understanding a provider's mental model is important to understanding a provider's actions. Notably, mental models for what constitutes "good care" do not always extend to respectful treatment of clients.
• Actors other than the provider can be critical to both diagnosing behavioural barriers and developing solutions to address them.
• Providers tend to prioritise actions and outcomes that are measured or on which their performance is evaluated. This factor was considered in the design of the client feedback system, a tactic for bringing attention to respectful care in assessing provider performance.