Results From a Multimethod Exploratory Scale Development Process to Measure Authoritarian Provider Attitudes in Democratic Republic of Congo and Togo

"There have been relatively few efforts to include validated measures of authoritarian attitudes in public health as explanatory variables to study or address attitudes as drivers of provider behavior concerning service delivery or quality of care."

Healthcare providers (HCPs)' behaviours - from adhering to clinical protocols to listening and responding to client questions - can significantly influence clients' experiences of care, adherence to recommendations, and likelihood of re-engaging with health services. Social and behaviour change (SBC) programmes can address the wide array of factors influencing provider behaviours, such as social norms. This study describes the process of developing measures for provider attitudes that may drive HCP behaviour across multiple health areas, focusing on 3 provider attitude domains - provider perceptions of clients, attitudes about providers' roles, and attitudes about gender roles - and ultimately combining them into an overarching domain of authoritarian attitudes.

Breakthrough RESEARCH developed provider attitude measures in 3 phases.

• In phase 1 (2019), survey items were developed based on literature reviews, and quantitative items were tested through a health facility survey conducted in the Democratic Republic of the Congo (DRC). HCPs (N=1,143) completed a 23-question survey focused on the 3 subdomains mentioned above. Phase 1 showed the provider attitude items had low scale reliability, and 8 survey items had low variability.
• In phase 2 (2021), as part of a larger mixed-methods study led by the Breakthrough ACTION project, cognitive interviews were administered to 17 HCPs in DRC to assess and improve understanding and interpretation of questionnaire items and response options. Results from the cognitive interviews of the 21 items retained from phase 1 found 16 questions were not well understood or had low response variability and thus modified, and 4 survey items were added to test different iterations of specific survey items.
• In phase 3 (2021), 52 family planning providers were sampled from urban health facilities in Togo to retest and validate 25 survey items (including 21 of the initial items, after 2 were dropped, and the additional 4 wording iterations of select items resulting from phase 2). The researchers identified authoritarian attitudes as the overarching domain based on the observed elements of dominance, inflexibility, and deprioritisation of others' autonomy. Exploratory factor analysis resulted in 1 provider attitude scale of 14 items reflecting authoritarian attitudes related to the 3 initial subdomains.

The researchers hypothesise that the attitudes measured will be related to attitudes about FP and other types of health care, as well as behavioural outcomes such as FP uptake. Public health practitioners working to measure and improve provider behaviour may consider expanding their scope to broader attitudes, such as those explored in this article, which may influence FP-specific and other behavioural drivers.

Future implementation research could (i) examine how power among community subgroups and facility providers (i.e., different cadres) intersects with and varies by gender and (ii) assess the influence that provider behaviour change programmes have on shifting power dynamics between HCPs and communities. In addition, they recommend that further testing be carried out with community health workers or other community-level providers to adapt the scale to non-facility-based providers. Further testing is also needed to explore how this scale performs in other contexts and in relation to a range of health outcomes.

"Provider behavior change programmers who seek to increase access to and uptake of health services should also address provider attitudes about their professional roles, their clients, and gender norms and further investigate how overall provider attitudes that are more authoritarian in nature could impact the quality of service delivery and affect clients' service uptake and continuation."

In conclusion: "Measuring provider attitudes using validated scales such as the scale presented in this article can identify areas for programmatic improvement by helping stakeholders understand drivers of provider behavior. This research highlights not only the result of a measurement development process but also the importance of iteration and testing with the target population in scale development, including the value of qualitative data, such as cognitive interviews, to improve quantitative measures."