Addressing Provider Stress and Unconscious Bias to Improve Quality of Maternal Health Care

Investigator: Patience Afulani, PhD, MD, MPH
Sponsor: NIH National Institute of Child Health and Human Development

Location(s): Kenya


Of the estimated 800 pregnancy-related deaths that occur daily, about two-thirds occur in sub-Saharan Africa, and for every woman who dies, about 20 others suffer various disabilities. Poor person-centered maternal health care (PCMHC) contributes directly to high maternal mortality and morbidity, and indirectly through decreased demand for health services. This K99/R00 application proposes training and research to develop expertise in stress and unconscious bias, advanced qualitative and mixed methods research, and implementation science methodology to inform the design, piloting, and evaluation of an intervention that targets provider stress and unconscious bias to improve PCMHC.

Poor person-centered maternal health care (PCMHC) contributes to high maternal and neonatal mortality in sub-Saharan Africa (SSA), and disparities in PCMHC are driving disparities in use of maternal health services. Little research, however, exists on how to improve PCMHC and reduce disparities. I seek to fill this gap with this project. I propose targeting health provider stress and unconscious bias as fundamental factors driving poor PCMHC and disparities in PCMHC. Health provider stress and unconscious bias are important to consider because:
(1) providers in low-resource settings often work under very stressful conditions;
(2) unconscious bias is prevalent in every society including SSA; and
(3) these factors are mutually reinforcing drivers of poor quality care and disparities in person-centered care.
To prepare me to develop my unique research program and extend the evidence base on interventions to improve PCMHC, I propose training and research during the mentored phase (K99) to extend my knowledge and skills in: (1) stress and unconscious bias; (2) advanced qualitative and mixed methods research; and (3) implementation science methodology. In the K99 phase, I will also conduct (1) multilevel secondary data analysis to examine individual level characteristics and potential system level stressors associated with PCMHC, focusing on the role of provider stress; and (2) structured and in-depth interviews with providers to examine the levels of provider stress and unconscious bias, and the types of stressors and biases in Kenya. The knowledge and skills gained in the mentored phase, as well as the results of the mentored research, will be instrumental to achieving the aims of the independent phase (R00), which are to: (1) design a multicomponent theory and evidence-based intervention that enables providers to identify and manage their stress and unconscious bias; (2) pilot the intervention to assess its feasibility and acceptability; and (3) assess preliminary effect of the intervention on: (a) provider knowledge, attitudes, and behaviors related to stress and unconscious bias; and (b) provider stress levels—using a pretest-posttest control group design. I will use the results of the pilot to refine the intervention and develop an R01 proposal for a multi-site evaluation with a larger sample and longer follow up, to assess impact on PCMHC.