The impact of social norms interventions on clinical behaviour change among health workers: protocol for a systematic review and meta-analysis

Cash transfer, maternal and child health outcomes: a scoping review in sub-Saharan Africa

BACKGROUND

Cash Transfer (CT) programmes can improve maternal and child health outcomes in low- and middle-income countries. However, studies assessing the effectiveness of these programmes on maternal and child health outcomes (MCH), beyond nutritional outcomes and service utilisation, remain inconclusive.

OBJECTIVES

We synthesized current empirical evidence on the effectiveness of these programmes in improving MCH outcomes and suggested a framework for reporting such outcomes. We focused on sub-Saharan Africa because of substantial operational differences between regions, and the need for MCH advancement in this region.

METHODS

This review searched PubMed Central and Google Scholar and supplemented it with a backward citation search for studies conducted in sub-Saharan Africa for the period between 2000 and 2021. Only peer-reviewed studies on CT that reported health outcomes beyond nutritional outcomes and service utilisation among women of reproductive age and children below 18 years old were included.

RESULTS

Twenty-one articles reporting studies conducted in six sub-Saharan African countries were identified. All studies reported health outcome measures, and programmes targeted women of reproductive age and children under 18 years of age. Of the 21 articles, 1 reported measures of mortality, 13 reported measures of functional status; 3 reported subjective measures of well-being, and 4 reported behavioural health outcomes. Across all categories of reported measures, evidence emerges that cash transfer programmes improved some health outcomes (e.g. improved infant and child survival, reduced incidence of illnesses, improved cognitive and motor development, improved general health, delayed sexual debut, lower transactional sex, etc.), while in some of the studies, outcomes such as depression did not show significant improvements.

CONCLUSION

Cash Transfer programmes are effective and cost-effective, with a real potential to improve maternal and child health outcomes in sub-Saharan African countries. However, further research is needed to address implementation challenges, which include data collection, and programme management.

Understanding COVID-19 vaccination behaviors and intentions in Ghana: A Behavioral Insights (BI) study

INTRODUCTION

Vaccine uptake is influenced by a variety of factors. Behavioral Insights (BI) can be used to address vaccine hesitancy to understand the factors that influence the decision to take or refuse a vaccine.

METHODOLOGY

This two-part study consisted of a survey designed to identify the influence of various drivers of people's COVID-19 vaccination status and their intention to take the vaccine in Ghana, as well as an experiment to test which of several behaviorally informed message frames had the greatest effect on vaccine acceptance. Data was collected from a total of 1494 participants; 1089 respondents (73%) reported already being vaccinated and 405 respondents (27%) reported not being vaccinated yet. The mobile phone-based surveys were conducted between December 2021 and January 2022 using Random Digit Dialing (RDD) to recruit study participants. Data analysis included regression models, relative weights analyses, and ANOVAs.

RESULTS

The findings indicated that vaccine uptake in Ghana is influenced more by social factors (what others think) than by practical factors such as ease of vaccination. Respondents' perceptions of their family's and religious leaders' attitudes towards the vaccine were among the most influential drivers. Unexpectedly, healthcare providers' positive attitudes about the COVID-19 vaccine had a significant negative relationship with respondents' vaccination behavior. Vaccine intention was positively predicted by risk perception, ease of vaccination, and the degree to which respondents considered the vaccine effective. Perceptions of religious leaders' attitudes also significantly and positively predicted respondents' intention to get vaccinated. Although perceptions of religious leaders' views about the vaccine are an important driver of vaccine acceptance, results asking respondents to rank-order who influences them suggest that people may not be consciously aware-or do not want to admit-the degree to which they are affected by what religious leaders think. Message frames that included fear, altruism, social norms were all followed by positive responses toward the vaccine, as were messages with three distinct messengers: Ghana Health Services, a doctor, and religious leaders.

CONCLUSIONS

What drives COVID-19 vaccine intentions does not necessarily drive behaviors. The results of this study can be used to develop appropriate COVID-19 vaccine uptake strategies targeting the most important drivers of COVID-19 vaccine acceptance, using effective message frames.

Behavioural factors associated with fear of litigation as a driver for the increased use of caesarean sections: a scoping review

OBJECTIVE

To explore the behavioural drivers of fear of litigation among healthcare providers influencing caesarean section (CS) rates.

DESIGN

Scoping review.

DATA SOURCES

We searched MEDLINE, Scopus and WHO Global Index (1 January 2001 to 9 March 2022).

DATA EXTRACTION AND SYNTHESIS

Data were extracted using a form specifically designed for this review and we conducted content analysis using textual coding for relevant themes. We used the WHO principles for the adoption of a behavioural science perspective in public health developed by the WHO Technical Advisory Group for Behavioural Sciences and Insights to organise and analyse the findings. We used a narrative approach to summarise the findings.

RESULTS

We screened 2968 citations and 56 were included. Reviewed articles did not use a standard measure of influence of fear of litigation on provider's behaviour. None of the studies used a clear theoretical framework to discuss the behavioural drivers of fear of litigation. We identified 12 drivers under the three domains of the WHO principles: (1) cognitive drivers: availability bias, ambiguity aversion, relative risk bias, commission bias and loss aversion bias; (2) social and cultural drivers: patient pressure, social norms and blame culture and (3) environmental drivers: legal, insurance, medical and professional, and media. Cognitive biases were the most discussed drivers of fear of litigation, followed by legal environment and patient pressure.

CONCLUSIONS

Despite the lack of consensus on a definition or measurement, we found that fear of litigation as a driver for rising CS rates results from a complex interaction between cognitive, social and environmental drivers. Many of our findings were transferable across geographical and practice settings. Behavioural interventions that consider these drivers are crucial to address the fear of litigation as part of strategies to reduce CS.

How effective are social norms interventions in changing the clinical behaviours of healthcare workers? A systematic review and meta-analysis

BACKGROUND

Healthcare workers perform clinical behaviours which impact on patient diagnoses, care, treatment and recovery. Some methods of supporting healthcare workers in changing their behaviour make use of social norms by exposing healthcare workers to the beliefs, values, attitudes or behaviours of a reference group or person. This review aimed to evaluate evidence on (i) the effect of social norms interventions on healthcare worker clinical behaviour change and (ii) the contexts, modes of delivery and behaviour change techniques (BCTs) associated with effectiveness.

METHODS

Systematic review and meta-analysis of randomised controlled trials. Searches were undertaken in seven databases. The primary outcome was compliance with a desired healthcare worker clinical behaviour and the secondary outcome was patient health outcomes. Outcomes were converted into standardised mean differences (SMDs). We performed meta-analyses and presented forest plots, stratified by five social norms BCTs (social comparison, credible source, social reward, social incentive and information about others' approval). Sources of variation in social norms BCTs, context and mode of delivery were explored using forest plots, meta-regression and network meta-analysis.

RESULTS

Combined data from 116 trials suggested that social norms interventions were associated with an improvement in healthcare worker clinical behaviour outcomes of 0.08 SMDs (95%CI 0.07 to 0.10) (n = 100 comparisons), and an improvement in patient health outcomes of 0.17 SMDs (95%CI 0.14 to 0.20) (n = 14), on average. Heterogeneity was high, with an overall I² of 85.4% (healthcare worker clinical behaviour) and 91.5% (patient health outcomes). Credible source was more effective on average, compared to control conditions (SMD 0.30, 95%CI 0.13 to 0.47, n = 7). Social comparison also appeared effective, both on its own (SMD 0.05, 95%CI 0.03 to 0.08, n = 33) and with other BCTs, and seemed particularly effective when combined with prompts/cues (0.33, 95%CI 0.22 to 0.44, n = 5).

CONCLUSIONS

Social norms interventions appeared to be an effective method of changing the clinical behaviour of healthcare workers and have a positive effect on patient health outcomes in a variety of health service contexts. Although the overall result is modest and variable, there is the potential for social norms interventions to be applied at large scale.

TRIAL REGISTRATION

PROSPERO CRD42016045718 .

Social norms interventions to change clinical behaviour in health workers: a systematic review and meta-analysis

Background

A social norms intervention seeks to change the clinical behaviour of a target health worker by exposing them to the values, beliefs, attitudes or behaviours of a reference group or person. These low-cost interventions can be used to encourage health workers to follow recommended professional practice.

Objective

To summarise evidence on whether or not social norms interventions are effective in encouraging health worker behaviour change, and to identify the most effective social norms interventions.

Design

A systematic review and meta-analysis of randomised controlled trials.

Data sources

The following databases were searched on 24 July 2018: Ovid MEDLINE (1946 to week 2 July 2018), EMBASE (1974 to 3 July 2018), Cumulative Index to Nursing and Allied Health Literature (1937 to July 2018), British Nursing Index (2008 to July 2018), ISI Web of Science (1900 to present), PsycINFO (1806 to week 3 July 2018) and Cochrane trials (up to July 2018).

Participants

Health workers took part in the study.

Interventions

Behaviour change interventions based on social norms.

Outcome measures

Health worker clinical behaviour, for example prescribing (primary outcome), and patient health outcomes, for example blood test results (secondary), converted into a standardised mean difference.

Methods

Titles and abstracts were reviewed against the inclusion criteria to exclude any that were clearly ineligible. Two reviewers independently screened the remaining full texts to identify relevant papers. Two reviewers extracted data independently, coded for behaviour change techniques and assessed quality using the Cochrane risk-of-bias tool. We performed a meta-analysis and presented forest plots, stratified by behaviour change technique. Sources of variation were explored using metaregression and network meta-analysis.

Results

A total of 4428 abstracts were screened, 477 full texts were screened and findings were based on 106 studies. Most studies were in primary care or hospitals, targeting prescribing, ordering of tests and communication with patients. The interventions included social comparison (in which information is given on how peers behave) and credible source (which refers to communication from a well-respected person in support of the behaviour). Combined data suggested that interventions that included social norms components were associated with an improvement in health worker behaviour of 0.08 standardised mean differences (95% confidence interval 0.07 to 0.10 standardised mean differences) (n = 100 comparisons), and an improvement in patient outcomes of 0.17 standardised mean differences (95% confidence interval 0.14 to 0.20) (n = 14), on average. Heterogeneity was high, with an overall I 2 of 85.4% (primary) and 91.5% (secondary). Network meta-analysis suggested that three types of social norms intervention were most effective, on average, compared with control: credible source (0.30 standardised mean differences, 95% confidence interval 0.13 to 0.47); social comparison combined with social reward (0.39 standardised mean differences, 95% confidence interval 0.15 to 0.64); and social comparison combined with prompts and cues (0.33 standardised mean differences, 95% confidence interval 0.22 to 0.44).

Limitations

The large number of studies prevented us from requesting additional information from authors. The trials varied in design, context and setting, and we combined different types of outcome to provide an overall summary of evidence, resulting in a very heterogeneous review.

Conclusions

Social norms interventions are an effective method of changing clinical behaviour in a variety of health service contexts. Although the overall result was modest and very variable, there is the potential for social norms interventions to be scaled up to target the behaviour of a large population of health workers and resulting patient outcomes.

Future work

Development of optimised credible source and social comparison behaviour change interventions, including qualitative research on acceptability and feasibility.

Study registration

This study is registered as PROSPERO CRD42016045718.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 41. See the NIHR Journals Library website for further project information.