Approaching Provider Behavior Change Monitoring and Evaluation with a Social-Ecological Lens: New Frontiers Brief

"The reality of service delivery is vastly complex, and applying a social-ecological lens to PBC [provider behaviour change] interventions acknowledges that complexity."



This brief, published by Breakthrough ACTION, explores the new frontiers of applying a social-ecological lens to the monitoring and evaluation (M&E) of provider behaviour change (PBC) interventions. It discusses insights and findings related to M&E and PBC and offers recommendations for programme planners and implementers working at the intersection of health systems strengthening, service delivery, and social and behaviour change (SBC) or otherwise working to understand and improve provider behaviour through PBC interventions. Although this brief focuses on family planning and reproductive health (FP/RH) service delivery and uses related examples, according to Breakthrough ACTION, it can be applied more broadly to other health areas.



The brief explains the necessity for a social-ecological lens within PBC as follows: "Evidence from the SBC field underscores that individual behavior change is more likely to be sustained when supported by social and structural change. Providers need the ecosystem in which they operate to be conducive to facilitating the behaviors that enable them to deliver high-quality, respectful care. Previous efforts to leverage programmatic approaches to improve provider behavior and client health outcomes... do not comprehensively account for the complexity of the providers’ real-life situations. Applying a social-ecological lens helps program planners and implementers consider this reality. By embracing complexity, they can work to identify and measure structural, social, and behavioral determinants of provider behavior across the ecosystem. With this information, they can then determine what types and combinations of interventions and strategies positively influence provider behavior at each level of the ecosystem."



This brief builds on Breakthrough ACTION's suite of PBC tools, which support the application of a social-ecological lens to design and implement PBC interventions. This suite of tools consists of the Provider Behavior Ecosystem Map and the Provider Behavior Change Toolkit (see Related Summaries, below). As PBC interventions that are designed and implemented using a social-ecological lens must be monitored and evaluated through the same lens, this brief seeks to support that process and uses the organising structure of the Provider Behavior Ecosystem (PBE) Map to discuss the findings and recommendations. In particular, the brief uses the seven nested concentric levels that influence provider behaviour identified in the Provider Behaviour Ecosystem Map. These levels are: The Individual Provider, Personal Relationships, The Client, Community Context and Social Norms, Workplace Environment, Health System Governance, and Country and Geopolitical Context.



The brief looks first at the current state of PBC M&E based on a desk review and technical consultations and shares findings and insights that are cross-cutting as well as PBE level-specific. Overall, the findings show reveal "significant variation in what is known and what is done to monitor and evaluate PBC interventions across the ecosystem. They also reveal notable gaps and challenges in the M&E of PBC interventions at each level of the ecosystem."



Cross-cutting findings, for example, show that most M&E work is concentrated at the following levels: The Individual Provider, The Client, and Workplace Environment. Little to no M&E work has been documented at the levels of Personal Relationships, Community Context and Social Norms, Health System Governance, and Country and Geopolitical Context. In addition, clear, consistent definitions of concepts, constructs, and variables related to PBC at each level of the ecosystem are lacking.



PBE-level-specific insights and findings show, for example, that at Individual Provider level, most focus is placed on measuring knowledge and skills of providers rather than actual behaviour change. In addition, most client-level studies focus on client experiences and client perceptions of providers. Providers rarely have access to information about client experiences and perceptions, which limits the potential of this information to influence PBC. Related to the workplace level, the findings show that most M&E efforts focus on providers' perceptions. Fewer studies directly evaluate the impact of workplace-level interventions on provider behaviour or assess causal relationships between workplace-level influences and factors and provider behaviour.



The brief then outlines cross-cutting and PBE level-specific recommendations for advancing and strengthening the application of the social-ecological lens to PBC M&E going forward. Cross-cutting recommendations include, for example: leveraging and triangulating existing data; developing and validating frameworks, indicators, and tools; and involving providers and other key stakeholders in the development and testing of M&E approaches, methods, and tools. Some examples of recommendations across all PBE levels include:

• The Individual Provider Level - The brief recommends the need to expand and refine individual-level PBC M&E beyond the narrow focus on knowledge and skills to also delve into attitudes, perspectives, self-efficacy, autonomy, and skills application in providers' professional capacity.
• Personal Relationships - As providers are influenced and affected by personal relationships with intimate partners, family, friends, colleagues, and others, future efforts should prioritise exploring how PBC interventions can better account for personal relationships and how they affect provider behaviour.
• The Client - To better understand how clients' characteristics and interactions with providers affect provider attitudes, biases, communication styles, and recommendations, the brief recommends expanding measurement at the client level. One should move beyond simply measuring satisfaction or understanding client perspectives, experimenting with approaches to link changes in provider behaviour to changes in client behaviour and outcomes.
• Workplace Environment - Here the brief, for example, recommends the need for more complexity-aware M&E systems and study designs that permit the evaluation of workplace-level influences and factors on provider behaviour over time.
• Health System Governance - To address the gap in M&E efforts at the health system governance level, programme planners and implementers must develop M&E systems and study designs to capture system-level data in a more timely and accurate manner.
• Country and Geopolitical Context - For example, programme planners can leverage existing national and population-based surveys (e.g., Demographic and Health Surveys, or DHS) for collecting data on providers, their behaviour, and client-provider interactions. These surveys can provide a wealth of information and insights, allowing for a more comprehensive understanding of how national-level influences shape provider behaviour and the quality of service delivery.

The brief is accompanied by a list of illustrative indicators for each of the above PBE levels:

• Click here for the list of Illustrative Indicators in English.
• Click here for the list of Illustrative Indicators in French.  

Click here for the French version of the 36-page brief in PDF format.