Beyond Bias

Beyond Bias' hypothesis was that by understanding what drives provider bias, small changes can be made to shift these biases and to thus remove provider-related barriers youth face when attempting to access sexual and reproductive care. As a result, young people will feel more confident and capable to make fully informed decisions around contraceptive use and will receive the contraceptive method of their choice, including long-acting reversible methods.

Beyond Bias used a multidisciplinary approach in an effort to enable a more nuanced understanding of the drivers, manifestations, and outcomes of provider bias and to create tailored interventions to address it. The approach entailed:

• Human-centred design, which aims to create feasible and viable solutions that meet users' needs and desires by actively engaging users to understand what drives them to be attracted to products or services. In partnership with Camber Collective, BERI, and Pathfinder, YLabs worked to gain a contextualised understanding of provider behaviours and attitudes by engaging providers and their communities to generate and test ideas to address bias. Further, ideas generated from the human-centred design process were vetted against existing evidence and informed by insights gathered from the design and segmentation research (see below).
• Market segmentation, which helps target messaging so that the product or service reaches the right people. Camber Collective worked collaboratively with Beyond Bias partners to understand what fuels provider behaviour and then to develop behavioural and attitudinal archetypes of providers. These archetypes were used to design specific interventions to shift provider behaviours and attitudes.
• Behavioural economics, which brings together economics and psychology to understand how people make decisions. By making small changes to contexts and environments within which we make decisions, behavioural economists aim to remove barriers to ensure that decision-making aligns with individuals' long-term desires and goals. BERI examined Beyond Bias' design from a behavioural economics lens to ensure that behaviour change can be measured. BERI is the project's evaluator.

The project has 4 phases:

1. Design research and segmentation - To begin, a literature review was conducted to understand the current state of knowledge regarding provider bias and develop a set of initial hypotheses to be validated through expert interviews. Major insights of the quantitative survey results highlight a wide array of factors that influence how providers serve clients. Given the broad range of provider behaviour, project partners conducted a segmentation analysis to understand the different sub-groups of providers that exist and the potential levers best suited to encourage positive behaviour change. It identified 6 key provider segments:
   • Detached Professionals: Well-trained and generally unbiased, though emotionally disconnected with youth
   • Average Passives: Aware of adolescent and youth sexual reproductive health practices, but somewhat biased and relatively unsympathetic to youth
   • Content Conservatives: Generally open-minded and youth-friendly, but distrustful of modern methods and independent women
   • Impromptu Sisters: Most connected with young clients, though also prone to believe they know what's best
   • Sympathetic Guardians: Well-intentioned, and though somewhat misinformed, and exhibiting overall high-quality youth service
   • Paternalistic Clinicians: Busy older doctors who, despite some progressive attitudes, show strong marital and parity bias
2. Solution development and prototyping - Based on the information collected in Phase 1, project partners designed and tested different solutions to implement in each country. They relied on idea-generating meetings and prototyping of different solutions with providers and adolescents and youth to assess desirability, scalability, potential for impact, and feasibility among users.
3. Implementation and evaluation - The project implemented prioritised solutions in each country and will tested whether these solutions successfully reduce provider bias through randomised control trials (RCTs) and quantitative and qualitative data collection.
4. Documentation and dissemination - Project partners documented experiences to contribute to the evidence on how to successfully implement multidisciplinary approaches within sexual and reproductive health. (See Related Summaries, below.)

Youth, Sexual and Reproductive Health, Rights

Adolescents and youth, who make up approximately one-quarter of the world's population, experience significant biological, physical, emotional, and behavioural challenges as well as several barriers to accessing quality sexual and reproductive health care. Guttmacher data (2016) indicate that 28 million sexually active adolescents in developing regions do not want a child within 2 years and 60% of these adolescents have an unmet need for contraception.

There are many contributing factors to this problem - among them: deep-rooted beliefs, attitudes, and norms about adolescent and youth sexuality that put adolescents and youth at risk for poor sexual and reproductive health outcomes. Because providers are typically members of the communities they serve, they often uphold the values and norms of their communities. Some providers may be unwilling to serve unmarried young people with contraception, some may encourage newly married young women to have a child first before using contraception, and others may withhold certain methods that they deem inappropriate for adolescents and youth, such as long-acting reversible contraception. As a result, adolescents' and youths' rights, and their health outcomes, may be compromised.

Key tips for addressing bias that emerged from this project include:

• Name bias, but don't shame bias: Create environments and conditions where providers feel supported and safe in admitting their own biases, without blame or fear of punishment.
• Acknowledge constraints; activate agency: Help providers focus on actions they can take to address bias which are feasible in their facilities, such as how they listen and speak to a young person, and what information about methods they provide.
• Reward growth over good: Reward providers' progress towards standards of unbiased care, rather than their ranked, absolute performance, alone.
• Connect bias to what providers care about: Demonstrate value for providers via recognition from their teams (public sector) and advice on business sustainability and customer retention (private sector).
• Celebrate providers' knowledge, experience, and commitment: Recognise providers as the experts and collaborators who can support their peer providers to improve service and build a bright future for youth.