Mistreatment during labor and delivery is a well-established global problem, yet research on effective interventions to change provider behavior is still quite limited. This presentation will highlight solutions for provider behavior change – part of the During Stage of the Circle of Care. A four-prong set of solutions was tested in Zambia and adapted and piloted in Liberia: 1) a pain management toolkit-a range of cues and tools placed through the ward to continuously prompt supportive care 2) a provider-client promise-a list of promises read out loud to clients upon admission and signed to set boundaries around acceptable provider care and shift power imbalances, 3) a feedback box-a means to default women into evaluating their experience of care and elevate their voice, 4) a reflection workshop-a safe space for providers to discuss facility norms and build motivation and a commitment to improve client care. The results of the evaluation showed statistically significant differences between clients in the treatment and control sites related to their experiences of disrespect and abuse and pain management support received.  The package of solutions, informed by behavioral science, holds promise to positively impact the experience of care of women in labor. The solution set was feasible to implement in both Zambia and Liberia and well received by health workers, thus suggesting its promise for scale. Additional research is needed to more rigorously test impact, refine intervention design to more effectively elevate client expectations of care, and ensure acceptability and feasibility at scale.

Driving early identification for infectious diseases such as tuberculosis (TB) in the Before stage of the Circle of Care is critical to effective care and reduction of community spread. For a high-risk population of urban, employed mid-age men in Southern India, low care seeking for TB is driven by symptom normalization, norms around masculinity and status, and concerns around slow, expensive or difficult-to-access services. Given that this segment has high digital access, a multilayer digital intervention was designed to counter these beliefs and enable faster care seeking. The intervention comprised a campaign via high-reach platforms such as Facebook, Whatsapp, and YouTube, interest-building interactive tools such as a chatbot, helpline, and engagement tools like a nearby facility locator, and self-assessment test for TB risk. The intervention was iteratively optimized over an 8 month period and reached 30 million non-unique individuals at a sustainable cost, with 400k engaged users. Symptom recognition targeted messaging was most effective, and different content formats performed better on different platforms. Interactive platforms saw high initial bounce rates and required design optimization to improve retention. The study yields important insights around the design of digital interventions in urban low income contexts in India, including platform and content choices. This model presents a novel approach to develop and target behavioral messaging approaches to demand generation for TB care seeking among the most vulnerable populations, and initializes a pathway to service delivery around testing and treatment in the TB Circle of Care.

The After stage of the Circle of Care applies SBC theory and practices to support clients in following through on counseling during the health contact (using contact to imply both facility and community-based health services). For postpartum family planning (PPFP) especially, there can be a lag between counseling and initiation of a method, as counseling happening during pregnancy, at childbirth or a postnatal contact may necessarily or by choice involve delayed start of contraception. Women who have not discussed PPFP with their partners frequently wish to before adopting contraception, especially where postpartum abstinence norms exist. Thus, PPFP is most effective when we embrace opportunities afforded by a continuum from antenatal to immunization visits in the extended postpartum period. In designing effective service integration, the Circle of Care guides us to anticipate women's needs at multiple visits, ideally linking FP discussions from one visit to another. Under USAID's Maternal and Child Survival Program, Jhpiego undertook several implementation research studies on PPFP in Liberia, Tanzania and Ethiopia, with varying models of PPFP integration. This presentation will tease out specific components of SBC design to support clients after a visit, facilitate self-care and encourage linkages from one visit to the next.