Caring for Providers to Improve Patient Experience (CPIPE): Intervention Development Process

"The labour and delivery ward in low-resource settings creates the perfect storm for...difficult situations - a combination of a difficult work environment, stressed and demotivated providers with rigid expectations of how a woman in labour should behave, and patients whose needs are not being met..."



The concept of person-centred maternal care (PCMC) - care that is respectful and responsive to individual women's preferences, needs, and values - is not equally experienced by all women: The most vulnerable groups tend to receive the poorest care. Disrespectful, abusive, and neglectful treatment of women during facility-based childbirth deters women from giving birth in health facilities. The intervention discussed in this paper, Caring for Providers to Improve Patient Experience (CPIPE), focused on two factors - provider stress and implicit bias - that drive poor PCMC and contribute to disparities in PCMC. This paper examines the iterative design process of the CPIPE intervention, which is a culmination of over 6 years of engagement in Migori County, Kenya.



The need for this intervention was informed by findings of initial research in Migori, where, per the Kenya demographic and health survey, 53% of births in the county occurred in health facilities, compared to the national average of 61%. Data collection took part in three phases, one beginning in 2016, one in 2019, and one in 2021, and involved surveys and in-depth interviews with women who had recently given birth, with providers, and with stakeholders in the county. (A local advisory board was established to ensure the intervention was relevant and feasible to the context and to develop local ownership - a critical component to the sustainability of the project.) In brief, this work highlighted that provider stress, burnout, and bias, as well as difficult situations during childbirth were key drivers of poor PCMC. Among the other provider-level drivers: inadequate knowledge and skill on various aspects of PCMC, perceived lack of time, forgetfulness, self-protection, and assumptions about women's knowledge and expectations. Many of the drivers of poor PCMC and sources of bias are modifiable, yet only 22% of providers surveyed in reported participating in a training to improve patient-provider interactions.



In addition to this formative research, the intervention design was informed by existing literature, behaviour change theories (social cognitive theory, trauma-informed systems, and an ecological perspective), and continuous feedback in consultation with key stakeholders. This process resulted in the development of CPIPE's 5 components, which together are designed to create an enabling environment for ongoing individual behaviour and facility culture change:

1. Provider training: includes didactic and interactive content on PCMC, stress, burnout, dealing with difficult situations, and bias, with some content integrated into emergency obstetric and neonatal care (EmONC) simulations to enable providers to apply concepts in the context of managing an emergency. The initial training days and times were selected in consultation with the CAB and county and facility leadership, who were all invited to participate in the training. All maternity providers in the intervention facilities were also invited to participate to facilitate a person-centred facility culture change. Almost all respondents highly recommended the training as something that would improve their performance at work, though it was important to provide a safe space where participants can talk about their experiences (e.g., of mistreating patients in the past) without fear of judgment or punishment. Suggested approaches to enhance engagement included making the trainings interactive, such as using scenarios, simulations, dramatisation, and team-building activities.
2. Peer support: Respondents noted that in these groups, providers can debrief after having difficult work experiences. It was also noted that peer support groups will enable providers to bring up issues they all experience, listen to each other, and freely discuss how they are dealing with the issues raised among themselves, without supervisors. Most of the respondents preferred in-person peer support group meetings (as opposed to an online platform), where providers can meet each other, express themselves easily, and have assurance of confidentiality.
3. Mentorship: All respondents appreciated the need for a mentorship programme, as this will bring together providers for knowledge exchange. It was recommended that what needs to be considered is expertise and competence, not just seniority.
4. Embedded champions: Some respondents noted that champions should be people who add value to the project and who are vocal, passionate, and dedicated. Suggested ways to motivate embedded champions included having periodic meetings, offering supportive supervision by the project team, having continuous assessment and designated roles for the champions, involving facility leaders, and forming WhatsApp groups for champions.
5. Leadership engagement: Described as key to ownership and sustainability, the steps of involving the county leaders in the health system and forming a community advisory board (CAB) to represent all stakeholders were described as commendable. Suggested ways to maintain leadership engagement included inviting leaders to the trainings, identifying a focal person for the project at the facility level to facilitate project activities, and having periodic meetings with the leaders to update them.

Per the earlier findings on gaps in individual psychological support, the team reached out to inquire about the presence of clinical psychologists or mental health counsellors in the county who could provide individual counselling to providers and identified two, who shared their phone numbers to be given to intervention participants.



Reflecting on the CPIPE intervention, which is ongoing in the county as of this writing, the team notes that addressing stress and bias together is significant, given research suggesting that deeply held biases are more likely to emerge when people are stressed. Furthermore, addressing provider stress and implicit bias together acknowledges both the vulnerability and power of providers, and it highlights outcomes not just for the patient but also for the provider. As a result, providers are less likely to feel blamed and more likely to support such an intervention. The framing of the intervention is meant to ensure that providers receive support to cope with stressors that impact their ability to provide PCMC and mitigate the effects of bias.



In subsequent manuscripts, the team will present data from a mixed-methods evaluation of the intervention describing the implementation process, lessons learnt during implementation, participant experiences and perceptions of the intervention, and preliminary effect of the pilot intervention on various outcomes. The team predicts that CPIPE "will advance the evidence base for interventions to improve PCMC and has great potential to improve equity in PCMC and maternal and neonatal health."