case study 5 from collaborative to combative

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• BMJ Glob Health
• v.7(12); 2022

Promising practices for the collaborative planning of integrated health campaigns from a synthesis of case studies

1 Health Campaign Effectiveness Coalition, The Task Force for Global Health, Decatur, Georgia, USA

Carol McPhillips-Tangum

2 CMT Consulting LLC, Decatur, Georgia, USA

Sumitra Devi Shrestha

3 Health Education Agriculture and Logistics Group, Kathmandu, Nepal

Preetha G S

4 International Institute of Health Management Research, Delhi, India

5 EngenderHealth, Delhi, India

Laura Nic Lochlainn

6 Department of Immunization, Vaccines & Biologicals (IVB), World Health Organization, Geneve, Switzerland

Esmael Habtamu

7 International Centre for Eye Health (ICEH), London School of Hygiene & Tropical Medicine, London, UK

Vivek I Patel

Gladys muhire.

8 Catholic Relief Services, Baltimore, Maryland, USA

Kristin N Saarlas

Associated data.

bmjgh-2022-010321supp001.pdf

Data are available in a public, open access repository. The eight case studies are available at: https://campaigneffectiveness.org/case-studies-on-integrated-health-campaigns/

A combination of public health campaigns and routine primary healthcare services are used in many countries to maximise the number of people reached with interventions to prevent, control, eliminate or eradicate diseases. Health campaigns have historically been organised within vertical (disease-specific) programmes, which are often funded, planned and implemented independently from one another and from routinely offered primary healthcare services. Global health agencies have voiced support for enhancing campaign effectiveness, including campaign efficiency and equity, through collaboration among vertical programmes. However, limited guidance is available to country-level campaign planners and implementers about how to effectively integrate campaigns. Planning is critical to the implementation of effective health campaigns, including those related to neglected tropical diseases, malaria, vitamin A supplementation and vaccine-preventable diseases, including polio, measles and meningitis. However, promising approaches to planning integrated health campaigns have not been sufficiently documented. This manuscript highlights promising practices for the collaborative planning of integrated health campaigns that emerged from the experiences of eight project teams working in three WHO regions. Adoption of the promising practices described in this paper could lead to enhanced collaboration among campaign stakeholders, increased agreement about the need for and anticipated benefits of campaign integration, and enhanced understanding of effective planning of integrated health campaigns.

Summary box

• Global health organisations have called for increasing cross programme or intersectoral collaboration to promote health campaign effectiveness, efficiency and equity; however, little has been documented about the promising approaches for planning integrated health campaigns, especially those related to neglected tropical diseases, malaria, vitamin A supplementation and vaccine-preventable diseases.
• Ten promising practices for the collaborative planning of integrated health campaigns were identified from a synthesis of eight case studies in six countries. In the campaign phase of preplanning, promising practices emerged related to coordinating bodies, securing broad participation at all levels, decision-making and pairing a campaign intervention with another familiar campaign. In the planning phase, promising practices emerged related to monitoring readiness, adopting digital tools, ensuring community acceptability and identifying missed populations. In the planning phase, promising practices were identified related to harmonising tools and setting up campaign workers for success.
• Country-based campaign planners and implementers, government health programmes, campaign funders, global institutions and non-governmental organisations can put into action these promising practices and other approaches to work towards a strategic balance of health campaigns and ongoing services for delivery of lifesaving interventions, shifting away from exclusively vertical (disease-specific) campaign approaches towards those that promote synergies and optimise efficiency, effectiveness and equity across health programmes and other sectors through enhanced coordination and collaboration.

Introduction

Many countries rely on a combination of ongoing health services and public health campaigns to extend the reach of interventions designed to prevent, control, eliminate or eradicate diseases. Public health campaigns are time-limited, targeted and intermittent activities deployed to address specific epidemiological challenges, fill delivery gaps or provide surge coverage for health interventions. Campaigns are used to control and treat neglected tropical diseases (NTDs) and malaria, provide vitamin A supplementation (VAS) and/or prevent and address outbreaks of vaccine-preventable diseases. More than 450 health campaigns have been planned worldwide each year since 2020. 1 The costs associated with health campaigns are considerable, with an analysis suggests that funders direct nearly US$7 billion annually towards these five priority programme areas. 2 Campaign costs are estimated to be at least US$2.1 billion. 2

Health campaigns have historically been organised within vertical (disease-specific) programmes, often funded, planned and implemented independently from one another and from primary healthcare services. In settings where multiple campaigns occur, planning and implementation may be carried out with little communication or collaboration among campaigns and with inadequate coordination with country health systems. Strategic and operational inefficiencies and inequities may result, which strain health systems, burden healthcare workers, weaken health services and limit campaigns’ potential health impact. 3

There is an increasing recognition that collaborative or integrated approaches to campaign planning and implementation could increase their effectiveness, efficiency and equity. 3 Global health agencies have voiced support for collaboration among vertical programmes. The WHO, the Global Polio Eradication Initiative, UNICEF and Gavi, the Vaccine Alliance, have each recently released guidance promoting campaign approaches that shift away from exclusively vertical programmatic approaches towards those that promote synergies and optimise efficiency through enhanced coordination and collaboration. 4–9

There are varying types of integration that programmes can undertake. 10 Full integration involves coordinating most or all typical campaign components (eg, microplanning, household registration, logistics, implementation and distribution, evaluation) to codeliver or simultaneously offer two or more health interventions at the point of delivery. Partial integration involves the collaboration or sharing of campaign components between vertical health programmes to improve efficiency and effectiveness of multiple campaigns, but without codelivery of interventions at the same service delivery points. 10–12 Planning a fully or partially integrated campaign is a complex and collaborative process that requires input from multiple stakeholders covering different health programmes and across the global, national, regional and local levels of governments and implementing partners. Frameworks exist to describe the dynamics of collaborative planning and governance in health. 13–18 However, despite the fact that planning is the foundation of effective health campaigns, little is documented on the planning of integrated health campaigns, especially those related to NTDs, malaria, VAS and vaccine-preventable diseases, including polio, measles and meningitis. This manuscript describes a novel effort to identify and document promising practices for collaborative planning of integrated health campaigns emerging from eight case studies.

Engagement of country partners

The Health Campaign Effectiveness (HCE) Coalition, launched in 2020 by the Task Force for Global Health, fosters learning and systems change related to health campaigns and brings together country leaders, donors, multilateral organisations, non-governmental organisations and specialists working in programmes operating health campaigns in NTDs, malaria, VAS and vaccine-preventable diseases, including polio. The HCE Coalition’s research and learning agenda, developed in consultation with a committee of scientific and technical advisors, articulated the need to study opportunities, identify promising practices and document outcomes of integrated campaigns. 19 In November 2020, HCE sought proposals from countries to identify, support and document case studies of collaborative planning approaches for integrated health campaigns. The funding criteria included that organisations needed to work closely with government agencies on integrated health campaign planning, complete the projects in 6 months and within a limited budget, and focus on integrated campaigns related to NTDs, malaria, VAS or vaccine-preventable diseases. Project funds were approved for convening stakeholders and collecting data to answer implementation research questions.

In 2021, projects meeting the criteria were selected in six countries in the Americas, Africa and Southeast Asia. Each project team tailored the case study to their own country context and needs. 20 Table 1 provides information about location, focus, objectives and methods used in each of the eight case studies. The primary study objectives spanned the need to identify enablers and barriers to collaborative microplanning; identify training and supervision needs of health workers, explore the acceptability of collaborative approaches to supply chain planning, logistics and management; and assess the feasibility of shared data systems, digital tools and communication strategies.

Descriptive characteristics of case study projects on collaborative planning for campaign integration

*Study descriptions are at campaigneffectiveness.org.

KII, key informant interview; LF, lymphatic filariasis; NTDs, neglected tropical diseases.

Two projects examined recent campaigns, while the rest explored potential or planned integrated campaigns or assessed a pilot integrated campaign. Three projects addressed integration across programme areas (NTDs and vitamin A, polio vaccine and vitamin A, NTDs and screening for chronic conditions), and the rest related to integration within programme areas. The project’s data collection methods included the review of administrative and campaign data and conducting key informant interviews at national, subnational and district levels and focus group discussions with community health workers or members ( table 1 ).

All projects required informed consent from participants prior to data collection and received approval from a local research ethics committee and followed country protocols on COVID-19. Full descriptions are available on campaigneffectiveness.org.

Approach to identifying promising practices

Case study projects followed a case study template describing the background and approach, results, challenges to the collaborative planning and mitigation strategies, promising practices, lessons learnt and implications for use and application of findings to future campaigns. Case studies reports and study tools were reviewed by subject-matter experts engaged with the HCE Coalition.

A review of the literature on the definitions of and criteria for evidence based, best or promising practices informed the definition of a promising practice for this synthesis as an action that campaign planners and implementers should consider incorporating into their campaign planning processes. 21–23 The process of analysis for the synthesis followed several steps. First, two coders reviewed each case study to extract key information and compiled an initial list of 65 project-specific promising practices in a spreadsheet. Second, using Miro, a collaborative whiteboarding tool, 24 the initial coded practices were grouped into larger categories and informed the development of ten overarching promising practices. Third, project-specific promising practices and the overarching promising practices were presented and discussed with advisors to the HCE Coalition.

Promising practices for the collaborative planning of integrated health campaigns

As the study team reviewed promising practices for collaborative campaign planning in the case studies, several phases of campaign planning emerged: the preplanning, planning and preparation phases. Ten overarching promising practices emerged from the synthesis of case studies in these phases, as follows:

In the preplanning phase, four practices emerged

Facilitate participatory decision-making by forming a coordinating body to oversee campaign integration and collaborate with regional/local coordinating bodies

While coordinating bodies are commonly used in vertical campaigns, this structure, with appropriate high-level governance, takes on vital importance role in integrated campaigns, which are more complex than vertical campaigns. For example, in Ghana, UNICEF and the Ghana Health Service, described the use of a national Emergency Operations Centre, chaired by the Director of Public Health, as an intersectoral planning and implementation committee responsible for campaign planning and coordination, implementation and resource mobilisation for the integrated campaign involving polio and VAS. 25 Subnational committees provided day-to-day monitoring and support, often in the form of reviewing daily performance and taking action to improve operations specific to integrated campaigns.

Secure broad participation, commitment and buy-in early in the campaign planning process by engaging stakeholders at all levels, including at the national, regional/district and local/community levels

In Vaupes, a department of Colombia in the Amazonas Region, the University of the Andes worked alongside the Ministry of Health (MOH) to integrate a NTD campaign against soil-transmitted helminthiasis, trachoma and ectoparasites. The project team underscored the importance of making campaign decisions in a participatory manner and obtaining endorsement for the integrated campaign early on from multiple stakeholders—including those at the national level, in the municipal and departmental health entities, and among authorities/leaders in the indigenous communities. 26

Enable timely and context-specific campaigns by allowing for decentralised campaign decision-making to meet unusual conditions (eg, multiple epidemics) in certain areas, as appropriate

During the study period, Guinea was facing various outbreaks including Ebola, Marburg, measles, yellow fever and the COVID-19 pandemic. The MOH had competing priorities to which they needed to respond. Although much campaign decision-making must be done centrally, the study team Fondation Santé et Développement Durable suggested that decentralising the integrated meningitis and measles campaign decision to allow for localised decision-making in the area known as the meningitis belt would allow for activities to start and enhance efficiency. 27

Embrace the learnings of previously successful platforms and approaches and build acceptance of the integrated campaign by pairing the campaign with another familiar and popular campaign

In Uttar Pradesh, India, the PATH project team working with state and local government, determined that an integrated campaign for lymphatic filariasis (LF) and soil transmitted helminthiasis could achieve a greater impact by embracing the learnings from Pulse Polio Immunisation, one of India’s largest and most successful health campaigns. 28 29 These learnings included creating opportunities for campaign activities to be reviewed at multiple levels (eg, national, subnational, community), conducting daily briefings with supervisors, field workers and officials, using interactive methods for capacity building, strengthening monitoring and evaluation, and involving relevant stakeholders for advocacy. 28

In the planning phase, four practices emerged

Ensure that planning for integrated campaigns assesses the readiness for campaign integration at different geographical levels

Projects described the use of readiness or preparedness assessments to assess whether a community or locale was moving towards readiness to implement an integrated campaign. For example, the Clinton Health Access Initiative (CHAI) and the National Primary Health Care Development Agency in Nigeria described efforts to redesign the readiness tools and templates used in the planning and implementation of the integrated measles and meningitis A to ensure that they work as well for integrated campaigns as they do in single intervention campaigns. 30 In addition, the project team in Ghana assessed preparedness for campaign integration at the national, regional and district levels across campaign activities, such as planning, coordination and financing; training on supplemental immunisation activities; monitoring and supervision; vaccine, cold chain and logistics; and advocacy, social mobilisation and communication. 25

Facilitate supply chain and logistics management, coordination meetings, training and real-time monitoring of campaigns by using technology and digital tools

A range of technology and digital tools were used and suggested for planning, managing and coordinating of integrated campaign planning, including video conferencing, short message/text messaging, electronic dashboards, health information management systems and digitised beneficiary lists. In Ghana, the project team described using bulk short message/texting and WhatsApp to regularly share campaign messages with communities and enable campaign workers to share daily progress and address emerging challenges in real time. 25 Use of these digital tools helped them with many campaign activities, including supply chain and logistics and data collection needed for supervision and monitoring.

Increase community acceptability of campaign interventions by enabling the community to observe trusted leaders’ actions (eg, demonstrating taking medications) and learn from culturally sensitive information, education and communication material addressing concerns about integrated interventions

In Uttar Pradesh, India, leaders and government officials consumed antifilarial drugs in public view during the mass drug administration to dispel concerns regarding the drug. 31 In Nepal, the project team Health Education Agriculture and Logistics (HEAL), assessing a pilot programme of partial integration of VAS and LF campaigns, developed informational materials (eg, posters) with inputs of health workers and volunteers, students and the community members to address the misconception that people with hypertension and diabetes should not take LF medicine. 32

Identify populations missed by traditional campaigns through nuanced strategies

In Nepal, the programme offering medicine for LF collaborated with the national VAS programme to find people who had been missed by the LF campaign. 32 The local authorities, with support of project team HEAL, developed the complementary monitoring and supervision approach during home visits, which consists of: providing information about the two campaigns being integrated to community members; enlisting community health volunteers to ask community members whether they had taken LF medication; identifying community members who had been missed by the LF campaign; educating community members about LF; referring community members to a nearby health facility to take LF medication and reporting information to the health facility. High coverage of LF medicine and VAS (85%+) was reported in the municipality in which the pilot project was conducted.

In the preparation phase, two practices emerged:

Meet the information and knowledge needs of the integrated campaign by harmonising tools, templates and guidance from standalone campaigns early in the campaign timeline

In Uttar Pradesh, India, PATH developed a single monitoring tool for the integrated campaign that harmonises the monitoring tools of single intervention campaigns and trained personnel in its use. 28 In Nigeria, the project team supporting the National Malaria Elimination Programme, Ibolda Health International, noted that an electronic dashboard was a critical tool. The dashboard was useful for monitoring campaign progress and providing real-time information to support training of healthcare workers, deployment of human resources, and coordination of logistics, community mobilisation and distribution of campaign commodities. 33

Set up campaign workers for success by providing appropriate training, supportive supervision, incentives and recognition, and promoting the transparency and accountability needed for timely remuneration

In Uttar Pradesh, India, the International Institute for Health Management and Research (Delhi) project team described providing campaign workers with a single training manual in the local language that details the integrated campaign activities to promote a systematic and unified process of campaign delivery. 31 The authorities in Uttar Pradesh also recognise and give awards to community health workers who deliver the integrated/vertical campaigns, in an annual event, called Accredited Social Health Activist (ASHA) Day.

These 10 promising practices are shown with illustrative tools from the projects and other partners ( table 2 ).

Overarching promising practices and illustrative tools

In addition, barriers may exist at multiple levels, including within countries (eg, lack of coordinated planning between ministries) and among campaign funders (eg, discordant funding priorities and timelines, differential pay scales for campaign workers). The barriers experienced in the projects and the mitigation are described in online supplemental table 1 ).

Supplementary data

This novel effort identified promising practices for the collaborative planning of integrated health campaigns in countries. These practices emerged from a synthesis of eight case studies across different health domains and six countries. Collaborative planning of health campaigns typically involves coordination, macroplanning, stakeholder and community engagement, microplanning, supply chain and logistics management, social mobilisation and communication, appropriate engagement, training, supervision and recognition of health workers, and monitoring. Complexity increases when each of these activities is conducted in an integrated campaign.

Research on health campaigns has typically focused on campaign outcomes (eg, coverage, access), but the appropriate planning of health campaigns—especially integrated campaigns—is foundational to their success. For this reason, it is important to identify promising practices that can help countries demystify and simplify the process of starting and collaboratively planning integrated health campaigns. Adoption of some or all of the promising practices described in this paper should lead to enhanced collaboration among key campaign stakeholders, increased agreement about the need for and anticipated benefits and potential challenges of campaign integration, and enhanced understanding of effective approaches for planning integrated health campaigns.

Several actions could help countries adopt the promising practices described in this paper at the level of campaign planners, implementers and partners. Campaign planners and implementers must be made aware that an initial set of promising practices for the collaborative planning of health campaigns has been identified. The HCE Coalition has initiated is disseminating the practices, so that countries may use them and document and share their experiences with one another. In this way, we can collectively build the evidence base to guide integrated campaign planning in the coming years. Although the promising practices described in this paper should not be expected to work equally well in every setting, the fact that these practices are grounded in the experiences of projects in different countries should help assure campaign planners and implementers that these practices warrant additional testing and potential adaptation to suit their specific needs. Campaign planners and implementers will need to advocate for the adoption and adaptation of these practices. To enhance the knowledge, skills, and self-efficacy of campaign planners and implementers of advocacy, resources should be developed and made available.

Campaign partners, which include government health programmes, campaign funders, global institutions and non-governmental organisations, should coalesce around the need to adopt and adapt strategies to plan for enhanced campaign effectiveness, efficiency and equity in integrated campaigns. Campaign partner endorsement of the promising practices described in this paper would be an important first step towards this goal. Campaign partners must commit to the development and implementation of strategies to mitigate existing programmatic and financial disincentives to campaign integration. Campaign partners should support documentation of what works and what doesn’t work and invest in implementation research to develop further evidence and to move from promising to evidenced-based best practices. Campaign funders should come together with an eye towards enhanced health campaign effectiveness, efficiency, equity and country ownership. Future studies can expand and build on this initial set of practices, to move beyond planning to incorporate findings across the campaign cycle.

Authorities in countries are highly motivated to optimise the use of limited human resources and technologies and maximise the impact of their health campaigns. During the COVID-19 pandemic, government health programmes were overstretched needing to add COVID-19 vaccination campaigns to ongoing activities. The practical, experience-based collaborative planning practices described in this paper will enable country partners and campaign-interested stakeholders to shift towards approaches that promote synergies through enhanced coordination and collaboration to increase campaign effectiveness.

Acknowledgments

The authors express their sincere gratitude to the Bill & Melinda Gates Foundation for their support to the Health Campaign Effectiveness Coalition Program at the Task Force for Global Health. We thank the eight project teams that developed the case studies described in this manuscript including the government agencies whose collaborative efforts were documented. We also acknowledge Alan Hinman and Patrick O’Carroll who reviewed this manuscript.

Handling editor: Seye Abimbola

Contributors: The authors express gratitude to the Bill & Melinda Gates Foundation for their support to the Health Campaign Effectiveness Program at the Task Force for Global Health. We thank the eight project teams that developed the case studies described in this manuscript including the government agencies whose collaborative efforts were documented. We also acknowledge Alan Hinman and Patrick O’Carroll who reviewed this manuscript.

Funding: This work was funded by the Bill & Melinda Gates Foundation -- Grant Number INV-01076 to the Task Force for Global Health’s Health Campaign Effectiveness Coalition Program .

Disclaimer: Under the foundation’s grant conditions, a Creative Commons Attribution 4.0 Generic License has already been assigned to the Author Accepted Manuscript version that might arise from this submission. The findings and conclusions contained within are those of the authors and do not necessarily reflect positions or policies of the Bill & Melinda Gates Foundation. The views expressed in their article represent those of the author and not necessarily those of their agencies.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Data availability statement

Ethics statements, patient consent for publication.

Not applicable.

Unveiling $5.4M Healthcare Fraud: The Case of Adarsh Gupta and the Medicare Scheme

H ealthcare fraud remains a pervasive issue, threatening the integrity of medical services and draining valuable resources from public programs. In a recent development, a federal jury convicted New Jersey doctor Adarsh Gupta for his role in a sophisticated Medicare fraud scheme, shedding light on the insidious nature of fraudulent practices within the healthcare system.

The Fraudulent Scheme by Adarsh Gupta

Adarsh Gupta, 51, of Sewell, was found guilty of orchestrating a fraudulent scheme that involved submitting over $5.4 million in fraudulent claims to Medicare for orthotic braces. The scheme, as revealed during the trial, relied on telemarketers to persuade Medicare beneficiaries to accept unnecessary orthotic braces. Gupta then signed thousands of prescriptions for these braces, often after brief telephone conversations with beneficiaries.

The telemarketing aspect of the scheme highlights the deliberate targeting of individuals who may be more susceptible to manipulation or coercion. Such practices not only exploit vulnerable populations but also undermine the trust and integrity of legitimate healthcare services.

A Lack of Medical Assessment

What makes this case particularly egregious is the lack of proper medical assessment and diagnosis conducted by Adarsh Gupta. Evidence presented at trial showed instances where he prescribed orthotic braces for conditions that clearly did not warrant such devices, including prescribing a knee brace for a Medicare beneficiary with previously amputated legs. These actions underscore a blatant disregard for patient well-being and ethical medical practices.

Legal Ramifications and Conviction

The conviction of Adarsh Gupta marks a significant milestone in the fight against healthcare fraud. The charges brought against him included three counts of health care fraud and two counts of false statements relating to health care matters. With a maximum penalty of 10 years in prison for each count of health care fraud and five years for each count of false statements, Gupta now faces the prospect of significant incarceration.

Investigation and Prosecution

The success of this case can be attributed to the diligent efforts of investigative agencies such as the FBI and the Department of Health and Human Services Office of Inspector General (HHS-OIG). Their thorough investigation uncovered the fraudulent scheme and provided the evidence necessary for prosecution. Additionally, prosecutors from the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the District of New Jersey played a crucial role in securing the conviction.

Impact of Healthcare Fraud

Beyond the legal ramifications for Gupta, the case highlights the broader impact of healthcare fraud on society. Such fraudulent activities not only jeopardize patient safety and trust in the medical profession but also strain public resources. By exploiting government-funded programs like Medicare, fraudsters divert funds that could otherwise be allocated to legitimate healthcare services, ultimately affecting the quality of care available to those in need.

Collaborative Efforts to Combat Fraud

In light of this conviction, it is imperative for stakeholders across the healthcare industry to remain vigilant and proactive in combating fraud . Collaboration between law enforcement agencies, healthcare providers, and the public is essential to effectively identify and prevent fraudulent activities. Measures such as increased scrutiny of billing practices, enhanced training on fraud detection, and the implementation of robust compliance programs can help safeguard against future incidents of healthcare fraud.

As Adarsh Gupta awaits sentencing on October 8, 2024, the case serves as a reminder of the consequences awaiting those who engage in fraudulent practices within the healthcare system. It underscores the commitment of authorities to uphold the integrity of medical services and hold accountable those who seek to exploit them for personal gain.

In conclusion, the conviction of Adarsh Gupta for his role in a $5.4 million Medicare fraud scheme underscores the ongoing battle against healthcare fraud. While this case represents a significant victory, it also underscores the need for continued vigilance and collaboration to safeguard the integrity of healthcare services for all.

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How To Fix Combative Relationships: Case Study

Are you stuck in a combative relationship?

Or do you have a combative personality and want to change it?

You have found the right article.

By the end of this article, you will know exactly what combative relationships are, and how to fix them.

What Are Combative Relationships?

How it should be, the psychology of one-upping, if the combative partner is the man:, if your partner is combative: show them the alternative, loving relationships mindset.

I will define a combative relationship as:

A relationship where one or both partners are more intent on showing superiority than on supporting each other

Combative relationships are defined by nasty games of “one-upping” and put-downs.

A combative partner will often use verbal and nonverbal attacks as a way of demeaning their partner, such as:

• Highlighting partner’s mistakes
• Focus on “winning”
• Refusing small favors “out of spite”
• Diminishing partner’s accomplishments
• Belittling partner’s ideas and contributions

Let’s see a few mainstays of a combative relationship:

Sign 1: Covert Aggression

Partners in combative relationships are in constant bickering.

Criticism is not always an open act of aggression like yelling and shoving though, and that’s why some people fail to diagnose where the problem lies.

Sometimes the criticism is nasty jokes , backstabbing, indirect criticism, covert aggression, and sarcastic put-downs.

Here is an example to stress the difference. Imagine the couple who is having difficulties parking, these are the two different approaches:

Direct Aggression : Of course there’s enough space to park, you’re a terrible driver, switch seats and lemme do it!

Indirect aggression:

Indirect : “Ahaha are you really asking me if there’s enough space? Ahaha a 30 ton truck could park there…

The first one could be mean , but the person saying it doesn’t hide and is not making fun of the other. It deals with the issue straight on and focuses on fixing it.

The second one is sneakier because it undermines your partner in an indirect way by making fun of her.

It’s also not solution oriented because it doesn’t solve the issue. Indeed the unconscious aim of the aggressor is to leave the issue open and up for longer discussion or escalation.

Look at a few real-life examples here:

They all seem like jokes. But it’s aggression presented in the guise of joking.

Psychology of Covert Aggression

Why do partners resort to passive aggression?

It’s a mix of power and insecurity.

It’s because, by highlighting the partner’s shortcomings the aggressor asserts his superiority in the relationship .

The aggressor’s comparative status increases and the aggressed diminishes.

Most people think it’s a question of low self-esteem, but that’s not correct. It’s egotism with high but fragile self-esteem that most often leads to aggression.

This is what social psychologist Roy Baumeister writes:

When researchers began to conduct careful prospective studies of family violence, however, the evidence for low self-esteem disappeared. The new buzzword among researchers on family violence is status inconsistency. (…) The violent husband is the man who thinks his daily life is not confirming his exalted opinion of himself.

Status inconsistency refers to the willingness -and belief- that one deserves the leadership role in the relationship. And whenever he feels under threat by her independence, he needs to lash out to re-assert his power and control.

The Hide and Seek Game of Covert Abusers

Since combative personalities are often insecure, accusing them usually goes nowhere.

The aggressor will hide behind the smoke screen of “it’s not true, it was just a joke”. This is a typical passive-aggressive technique .

Maybe they will even add a gaslighting zinger such as “don’t be so touchy”, just to push you on the defensive.

One Aggressive Partner Is Enough

In many combative relationships, it’s not both partners who are aggressive.

It’s instead one partner who feels the need to assert his superiority while the other partners the other party reacts in defense.

In a way, both are trapped in a combative relationship, but neither knows any better and so it keeps going on and on forever.

A relationship with endemic aggression is a failed relationship.

No relationship, and least of all a romantic one, needs aggression and you should not settle for it.

Your relationship should be your sanctuary of understanding, warmth, and support. When you don’t get warmth and support from your partner you might as well (try to) string a one-night stand after the other.

Read more on how to turn criticism into constructive feedback:

• Fixing criticism in relationships

Sign 2: One-Upping

Covert aggression is terrible, but one-upping is even sneakier.

The partner one-upping the other is in need of feeling superior and protecting their ego.

Albeit not exclusively, it is mostly a men’s issue, and it often goes hand in hand with a fixed mindset .

A partner with a fixed mindset believes that their qualities are set in stone, and their qualities define who they are.

So any time a man sees a woman outperforming him -smarter, more confident, richer, etc.-, they feel inferior to her. This is hard to swallow for many men and particularly so for fixed mindset men because they see every single instance as another proof of who they are in general. So every single “loss” mean they are “losers”.

So they are constantly struggling to prove themselves better than their partners in an endless, incessant “who’s better” war.

Notice the very first skit here:

Elena brags a bit about her number of followers on Instagram. Cardone is quick in highlighting how her followers are actually his followers. He basically negates her notoriety and one-ups her to show he’s the real boss and the real star of the two.

To address this issue at the core:

• Develop a growth mindset

One-upping people means tearing them down.

But people in healthy relationships don’t tear each other down. People in healthy relationships build each other up .

Confident men who care about their partner don’t negate their wife’s successes, but compliment, congratulate them, and make them feel great about it. See the difference:

Weak One-Upping Man:

Her : I have just hit 10k Instagram fans today! Him : Oh, cool, and do you think that makes you a better person now? Who cares about followers… 

If she’s bragging about it, it’s obviously important to her! If she’s bragging about it to you, she cares about what you think.

The man here probably doesn’t have 10k fans and is afraid of being inferior because of it.

So he tries to tear down her whole metrics of success and, in the process, her whole judgment (very, very demeaning).

Confident Man :

Her : I have just hit 10k Instagram fans today! Him : Wow, congratulations baby! Give me a hug, we should have a toast to that! How do you feel about it.. 

The difference is light day and night, right?

Here the man is making her feel great for her accomplishment. But he is also communicating something deeper: that he appreciates her and her successes and that he can partake in that success because they are a team.

This second man is the kind of man she will want to be around and share her stories with. And, very possibly, her whole life.

How To Fix Combative Relationships

First off, you need to understand you’re in a combative relationship.

And if you are a combative personality, you need to admit it to yourself.

If you are reading this article, you either looked for it and you know, or you know now. So own it.

In all frankness, a proverb springs to mind:

The smallest dogs are the ones who (need to) bark the loudest.

Men who are leaders of their relationship do NOT need to state it and do not need to prove it.

If you are the one aggressing then, you need to work on yourself first and foremost. In the meanwhile, fake it till you make it:

• Stop aggressing
• Consciously replace aggression with warmth

Breaking the vicious circle is sometimes all that’s needed. Everyone prefers a supportive relationship and once you experience the benefits you will not want to look back.

You will still probably regress from time to time, but keep staying vigilant, and little by little you will completely stamp out the aggressive behavior.

If your partner is the aggressor, try this:

Make them feel loved and appreciated in spite of their s hortcomings.

People long to be who they are. But they are scared that they are not enough, and that’s why they put on all that big fight. But deep down, we all naturally long for a place and a relationship where we can let our guard down and be loved for who we are.

Teach Them The Right Way

But of course, before you get there, you might need to do some teaching.

You will not just show warmth, indeed, but you will also “punish” first the bad behavior with some tough love and operant conditioning.

To show how we will move away from the Instagram example and use the situation from the video where she rudely refused to give him his pen:

Her (swats his hand away) Him : (warmly, genuinely hurt) why are you doing that. I need a pen, I would happily lend you my pen if you needed one Her : Sorry that was a bit rude, maybe but why should you take my pen, get your own pen Him : No, I just needed it for a second, but the pen is not the point, it goes deeper and I’ve seen this dynamic a few times now and I feel we should address it. The point is that we’re together now and if you needed a pen right now I’d be happy to help you with a pen right now. And if tomorrow you need help in some other way I can help you with, say a shoulder to cry on like it happened last week, I’m happy to help you in that way. Because I want to see you happy. I see relationships as a way of helping each other. So if one day, it’s me who needs your support, I’d also appreciate you to help me too. I believe those are the best relationships, the ones where we are a team. You’re my co-pilot and we are stronger as a team. Don’t you think that would be a better relationship? Her : Yeah.. Sorry I just thought you wanted to steal my pen Him : All good

The first time you do it, your partner will likely feel ashamed of their behavior. And that’s great because it means they understand and care.

Do it a few times and your relationship will quickly grow stronger and more collaborative than you thought possible

Exceptions : Of course, not everyone can be fixed. Fringe cases are the real narcissistic, heavily egocentric, power-hungry , abusive , controlling , and jealous-paranoids .

These are the mindsets of benevolent relationship leaders:

• You understand that the mindset of trying to win and showing yourself superior to your partner is ultimately a weak one driven and motivated by internal deficiencies
• You know that strong and confident leaders don’t push other people down and don’t feel the need to show their superiority.
• You know that enlightened leaders do the exact opposite: they help the people around them get nearer their level, make them feel great, and build them up.

Men in great relationships don’t dictate but instead, make their woman part of their common decision-making. Or even delegates to her in any realm where she’s better suited to lead or decide.

Ironically, the moment you stop “proving” yourself superior and focus instead on caring about your partner is also the moment you become the leader of that relationship.

Combative relationships are often the consequence of weak egos and keep going out of vicious circles’ momentum.

But the moment you interrupt it that vicious circle and replace it with something better, chances are high it will change for the better.

About The Author

Lucio Buffalmano

Related posts.

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How to Find a Loyal Partner: 99 Traits of Faithfulness

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This is analogous to performing an MRI on an unproductive, competitive work team that produces at the level that neither represents their talents and abilities nor produces results! The energy field of this experience is not conducive to high levels of productivity, creativity and safety. As in science, if dynamics and relationships are broken down to their elemental state it becomes easier to understand and shift them into desired states.

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Our work is based upon the following collaborative hypothesis:

If a member/team can:

• Commit to a shared goal
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Then they will achieve the intended results with ease and grace. They will be generating 5 specific dimensions of energy that result in a highly productive field known as the collaboration meme. This maximizes the use of the intellectual capital, emotional dispositions and highly developed skills of the team towards the accomplishment of the shared goal.

We call our work in this area the Science of Collaboration because it is a definable and a repeatable process. When all the fields are aligned on each of the dimensions a third thing occurs – potential is released. Potential that was not previously available can now make that which was impossible now possible.

We were called into work with a business analytics group for a mid size pharmaceutical company. It was a cost center not responsible for generating revenues or expense reduction. There was a new first time manager who wanted to do well and make an impression on management.

So the first step in our process was to establish an aggressive stretch goal, which does a number of things. The response to this activity is normally the following:

• Limiting beliefs surface and seen as sarcasm or negative comments
• Issues are either raised or hinted at suggesting others would “block us”
• Personal issues about fear of failing or not being smart come up clouding the conversation and making it difficult
• Strengths/opportunities were discussed after a venting session was completed

We finally came up with the shared goal of making a $50 M contribution in profits to the company even though they had no direct responsibility for revenues or cost cutting!

The next steps:

• Formulate the business plan and clarify roles and responsibilities.
• They agreed upon six projects that would generate profits or reduce overhead.
• Each of the six reports took the point on a project and went to work.

I worked with the manager in affirming his capabilities and processing his issues as they came up in dealing with anxious reports. We both worked with the team in processing them through their issues and back into a productive state.

Example: The person who generated the reports for the health care costs of the 4,000 employees came up with the idea to bring in two other vendors to bid on the coverage. They wound up shifting vendors and saving $1 M per month. That’s $12 M per year. The other five projects were not as financially impactful but were highly creative and added to the total.

The net impact of this cost centers work besides their day-to-day function of business analysis was generating an unexpected $37 M in profits in a 12-month period of time.

There was a dramatic belief restructuring that took place:

From: Who do we think we are?             To: I’m very smart and can make a big impact!

From: That’s not our job!                         To: I’ll do whatever I need to do to contribute.

This was also true with attitudes and behaviors as they practiced and elevated their collaborative skills in making this happen. These individuals will never be the same after this experience. They did something that in the beginning they not only knew they couldn’t do but weren’t supposed to do.

The impossible became possible and then manifested as $37 M. Their approach to everything in the future is now different.

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