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The Provider Behavior Ecosystem Map is a thinking tool that helps you think more systemically about provider behavior by highlighting the many factors that influence provider behavior and their interactions. Using it is a first step in the design—or adjustment—of supportive provider behavior change initiatives. The guidance below demonstrates how to use it to lay focused groundwork for the design or modification of these initiatives.

Record your initial thoughts on which factors influence provider behavior in your context. You may want to use this worksheet 

throughout this process.

Conduct assessments and/or review secondary research to identify which factors are relevant and most influential for your group of providers. Involve providers, supervisors, clients, educators, and other stakeholders in this process.

Prioritize factors according to their degree of influence on provider behavior in your context. (See these resources: Provider Behavior Assessment for Social and Behavior ChangeProvider Needs Assessment Framework, and Trending Topic on Provider Behavior Change). 

 

Coming in 2021: a diagnostic tool to help you identify the most influential factors for provider behavior in your context.

Determine which factors you can address through your initiative given your mandate, focus, capabilities, budget, and other considerations. 

Collaborate with other programs and organizations to ensure a coordinated approach that addresses as many factors as possible and achieves greater impact.

Coordination and collaboration are key to shaping and influencing provider behavior in scalable and sustainable ways.

Engage providers, supervisors, managers, clients, educators, and other relevant stakeholders to design or modify your provider behavior change initiative. Use the prioritized factors to inform the development of program strategies and activities.

Provider behavior change tools and initiatives should complement existing quality improvement or quality of care guidance, processes, and tools to ensure broader impact.

Implement, monitor, and evaluate the initiative. Be sure to remain aware of factors not addressed by your initiative and their potential impact, as they can change over time. 

There are many settings in which you could apply the Provider Behavior Ecosystem map, including the following:

Think through all the factors that could influence provider behavior in your context and make decisions, together with providers and other stakeholders, about which ones your initiative should address. You may want to use these printable cards to enable participants to explore each factor, its importance, and its interrelationships.

Use the ecosystem map to encourage partners, donors, or government counterparts to consider a broader range of multi-level factors influencing provider behavior.

Share information in the ecosystem map with quality improvement teams, or other facility-based committees, as provider behavioral issues are flagged to support more holistic thinking about the root causes of provider behavior.

Use the ecosystem map to inform choices about what to measure or to guide the selection of indicators as you develop and refine monitoring and evaluation plans for provider behavior change initiatives targeting healthcare facilities.

Use the ecosystem map to identify knowledge gaps around provider behavior, and strengths and weaknesses in current programming. This analysis can then guide decisions about formative or other research, as well as where programmatic adjustments could be made as part of course correction during implementation. 

To begin thinking about factors influencing provider behavior in your context, use this worksheet as you review the map. This worksheet will help you document early assumptions about what does and does not influence provider behavior in your setting. You can then conduct assessments and apply tools together with providers and other relevant stakeholders to identify the most influential factors and check them against initial assumptions in this worksheet.

 

Breakthrough ACTION is developing companion resources to this ecosystem map that will help you and your stakeholders identify and prioritize local factors influencing provider behavior and design solutions to address those factors. This suite of resources will allow you to design, implement and evaluate impactful provider behavior change initiatives.

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The interrelationships in the ecosystem map help you see the interconnectedness of influences on provider behavior. Since providers operate in complex systems, a change in one part of a system can impact another part of the system. When deciding which factors you will address in your provider behavior change initiatives, you should also consider the components that influence or are influenced by those factors. By thinking about interactions between components, you may find that you need to either shift the focus of your activities or design additional activities to address linked components. Since no single organization or project can tackle all interrelated components, collaboration and coordinated efforts are essential.

The story below highlights the importance of considering the interrelationships in a provider’s ecosystem:

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A recent nursing school graduate is interviewing for positions at different health clinics offering family planning/reproductive health (FP/RH) services in the province where he was born and raised. During job interviews, he asks clinic staff whether they offer youth-friendly FP/RH services and how they engage local youth in health promotion. He is particularly interested in adolescent and youth FP/RH given his past experiences and medical education and training.

Growing up in a large town, his unmarried friends—both men and women—were often turned away from the local health clinic when seeking information and guidance on reproductive health and modern contraceptive methods. The local doctors and nurses frequently told his unmarried friends that they had no reason to be asking about such things, citing that people should wait until marriage to have sex. They also advised them to not have sex and to return to the clinic after they were married. Though he never shared this with his friends, he agreed with the response of these doctors and nurses. After all, it was what he had always heard from his grandparents, parents, and other family members: unmarried people should not have sex with anyone, and married people should only have sex with their spouse.

Not  until nursing school did he learn about the importance of adolescent and youth FP/RH in a course with a highly respected professor. This professor taught him and his classmates about the importance of disease prevention and health promotion across the life course. She emphasized the need to meet young people where they are and empower them with medically accurate and complete information to help them make informed decisions about their health and well-being from an early age. In this course, he began to reconsider both his earlier thinking about who should and should not have access to essential FP/RH information and services and why he thought that way in the first place.

This example highlights diverse components and illustrates several interrelationships across the Provider Behavior Ecosystem that influence the recent graduate who will soon become a formal provider. 

His upbringing in a town where unmarried people having sex is socially prohibited highlights components under COMMUNITY CONTEXT AND SOCIAL NORMS like:

  • Socio-cultural norms, gender norms, social sanctions, social stigma, and discrimination.

 

In this example, socio-cultural norms are reflected in the community at large embracing the idea that people should wait until marriage to have sex, and social sanctions are seen in the differential treatment towards unmarried people seeking sexual and reproductive health  information and services at the local health facility.

These components then influence and are influenced by components at other levels. Here, the doctors and nurses are not only influenced by socio-cultural norms and social stigma at the level of COMMUNITY CONTEXT AND SOCIAL NORMS, but also influence it themselves through their actions and words.

 

At the level of THE INDIVIDUAL, some components that come into play are:

 

  • Empathy toward client, bias and partiality, attitudes and values, perceived norms, and power dynamics.

 

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The doctors and nurses uphold perceived norms that promote or allow stigmatization based on marital status when they themselves deny access to information and service around sexual health and modern contraceptive methods to unmarried people. They also demonstrate a lack of empathy for the potential client’s situation in seeking FP/RH information and services.

Components under COMMUNITY CONTEXT AND SOCIAL NORMS and THE INDIVIDUAL also influence the elements within CLIENT EXPERIENCE, including:

 

  • Relationship dynamics, agency and power, authority bias, and perceptions.

Perceptions and agency and power are evident in the way that doctors and nurses view and limit the health-seeking of unmarried people. Providers usually have more power than clients in the healthcare setting as health service gatekeepers, allowing or denying access based on their individual attitudes and perceptions. Furthermore, we learn that the nursing school graduate agrees with the actions and words of the doctors and nurses because it reflects what he learned from his own family members. In this way, THE INDIVIDUAL also intersects with PERSONAL RELATIONSHIPS. Related components under PERSONAL RELATIONSHIPS are:

  • Attitudes, values, and behaviors; culture and religion; and social networks.

Though there are more components and interrelationships that can be teased out of this example, the above description begins to demonstrate how and why provider behavior is the outcome of a complex set of factors internal and external to providers. This example also underscores the importance of investing time and effort in familiarizing yourself with actors, entities, and other elements in your target context. Greater familiarity will allow you to better identify and assess the diverse components influencing provider behavior and the interrelationships between them within your target context.