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PLoS One. 2019 Apr 17;14(4):e0214922. doi: 10.1371/journal.pone.0214922. eCollection 2019.

Categorizing and assessing comprehensive drivers of provider behavior for optimizing quality of health care.

Author information

Surgo Foundation, Seattle, Washington, United States of America.
Final Mile Consulting, Mumbai, India.
Final Mile Consulting, Chicago, Illinois, United States of America.
Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada.
Bill & Melinda Gates Foundation, New Delhi, India.
India Health Action Trust (IHAT), Uttar Pradesh Technical Support Unit (TSU), Lucknow, India.
Department of Global Health & Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America.
Department of Global Health, University of Washington, Seattle, Washington, United States of America.


Inadequate quality of care in healthcare facilities is one of the primary causes of patient mortality in low- and middle-income countries, and understanding the behavior of healthcare providers is key to addressing it. Much of the existing research concentrates on improving resource-focused issues, such as staffing or training, but these interventions do not fully close the gaps in quality of care. By contrast, there is a lack of knowledge regarding the full contextual and internal drivers-such as social norms, beliefs, and emotions-that influence the clinical behaviors of healthcare providers. We aimed to provide two conceptual frameworks to identify such drivers, and investigate them in a facility setting where inadequate quality of care is pronounced. Using immersion interviews and a novel decision-making game incorporating concepts from behavioral science, we systematically and qualitatively identified an extensive set of contextual and internal behavioral drivers in staff nurses working in reproductive, maternal, newborn, and child health (RMNCH) in government public health facilities in Uttar Pradesh, India. We found that the nurses operate in an environment of stress, blame, and lack of control, which appears to influence their perception of their role as often significantly different from the RMNCH program's perspective. That context influences their perceptions of risk for themselves and for their patients, as well as self-efficacy beliefs, which could lead to avoidance of responsibility, or incorrect care. A limitation of the study is its use of only qualitative methods, which provide depth, rather than prevalence estimates of findings. This exploratory study identified previously under-researched contextual and internal drivers influencing the care-related behavior of staff nurses in public facilities in Uttar Pradesh. We recommend four types of interventions to close the gap between actual and target behaviors: structural improvements, systemic changes, community-level shifts, and interventions within healthcare facilities.

Conflict of interest statement

We note that several of the authors [SSh, RP] are employed by a commercial company, 'Final Mile Consulting', who designed instruments and analyzed data under the direction of the funding organization. Final Mile Consulting sub-contracted parts of data collection to Market Resonance, a market research company. In addition, several authors are - or were at the time the study was conducted - employees of the funding organization (SK, EE, MJ, TW, SKS). This does not alter our adherence to PLOS ONE policies on sharing data and materials, as all data and protocols underlying this study are shared, and neither the commercial company nor the funding organization declare any bias towards particular study outcomes.

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