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

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


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.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Child Health*
  • Female
  • Health Personnel*
  • Humans
  • India
  • Infant, Newborn
  • Male
  • Quality of Health Care*

Associated data

  • Dryad/10.5061/dryad.6974t14

Grants and funding

This study was funded by Surgo Foundation, a non-profit organization. The funder provided support in the form of salaries for authors [SK, EE, MJ, TW, SKS], and senior leadership at the funding organization were involved in study design, data collection and analysis, decision to publish, and preparation of the manuscript. The funder engaged in a contractual relationship with Final Mile Consulting [SSh, RP] and provided grants to the University of Manitoba [BR] which operates the India Health Action Trust [ST, SKu] for support with design of research instruments, implementation, and data analysis. Surgo Foundation also entered an MOU with the Bill and Melinda Gates Foundation [MS] for collaboration on the research. Final Mile Consulting sub-contracted parts of data collection to Market Resonance, a market research company. The specific roles of all authors are articulated in the ‘author contributions’ section.