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Context 1
... approach to quality assessment is to assess at three levels: policy level, service delivery point (SDP), and client level [17,18]. At each level, quality is measured from a different perspective (see Figure 1). At the policy level, the intention of the government to provide good quality services is measured; in other words, the degree of policy commitment to the concept of quality is ascer- tained. ...
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Background
The INPAC project aims to evaluate the effectiveness of integrated post-abortion family planning (PAFP) services into existing hospital based abortion services in China. A qualitative study was conducted in three provinces to contribute to developing effective PAFP services through understanding influences on contraceptive use, experienc...
Pakistan has recognized that the promotion of voluntary family planning services can have powerful impacts on the development of a country, kick-starting the shifts and changes needed to reap the benefits of the demographic dividend and improving considerably the health of women and their children. In light of this financial commitments, how much w...
The introduction of the universal two-child policy in 2016 marked a major social transition in China and raised a requirement for family planning services; however, the turnover in family planning staff poses a challenge to satisfying the requirement. Thus far, after implementation of the policy, there have been few surveys investigating turnover i...
Citations
... Quality of contraceptive care is fundamentally different from other clinical areas, such as maternal health, due to the centrality of the counseling experience itself, rather than a medical intervention, and the fact that contraceptive choice is a preference-sensitive decision without one best outcome for all people . Researchers continue to grapple with a lack of agreement about standardized quality measures, particularly related to contraceptive counseling-the cornerstone of client-provider interactions in family planning (Tumlinson 2016;RamaRao and Jain 2016;RamaRao and Mohanam 2003). Variability in context-specific definitions of a "positive" counseling experience further complicates measurement (Holt et al. 2018;Dehlendorf et al. 2013). ...
The lack of validated, cross-cultural measures for examining quality of contraceptive counseling compromises progress toward improved services. We tested the validity and reliability of the 10-item Quality of Contraceptive Counseling scale (QCC-10) and its association with continued protection from unintended pregnancy and person-centered outcomes using longitudinal data from women aged 15-49 in Burkina Faso, Kenya, and Nigeria. Psychometric analysis showed moderate-to-strong reliability (alphas: 0.73-0.91) and high convergent validity with greatest service satisfaction. At follow-up, QCC-10 scores were not associated with continued pregnancy protection but were linked to contraceptive informational needs being met among Burkinabe and Kenyan women; the reverse was true in Kano. Higher QCC-10 scores were also associated with care-seeking among Kenyan women experiencing side effects. The QCC-10 is a validated scale for assessing quality of contraceptive counseling across diverse contexts. Future work is needed to improve understanding of how the QCC-10 relates to person-centered measures of reproductive health.
... Quality of care (QoC) frameworks include implementation strength. In general, ISA fits into the Donabedian framework and its three dimensions of structure, process, and outcomes, and specifically for family planning, the Bruce-Jain framework divides QoC into six elements of FP programs [7][8][9]. Strength domains for this family planning (FP) assessment focus on the structural side of these frameworks and include training, supervision, FP method choice and availability, demand generation activities, and accessibility [7]. ...
Background
Data that capture implementation strength can be combined in multiple ways across content and health system levels to create a summary measure that can help us to explore and compare program implementation across facility catchment areas. Summary indices can make it easier for national policymakers to understand and address variation in strength of program implementation across jurisdictions. In this paper, we describe the development of an index that we used to describe the district-level strength of implementation of Malawi’s national family planning program.
Methods
To develop the index, we used data collected during a 2017 national, health facility and community health worker Implementation Strength Assessment survey in Malawi to test different methods to combine indicators within and then across domains (4 methods—simple additive, weighted additive, principal components analysis, exploratory factor analysis) and combine scores across health facility and community health worker levels (2 methods—simple average and mixed effects model) to create a catchment area-level summary score for each health facility in Malawi. We explored how well each model captures variation and predicts couple-years protection and how feasible it is to conduct each type of analysis and the resulting interpretability.
Results
We found little difference in how the four methods combined indicator data at the individual and combined levels of the health system. However, there were major differences when combining scores across health system levels to obtain a score at the health facility catchment area level. The scores resulting from the mixed effects model were able to better discriminate differences between catchment area scores compared to the simple average method. The scores using the mixed effects combination method also demonstrated more of a dose–response relationship with couple-years protection.
Conclusions
The summary measure that was calculated from the mixed effects combination method captured the variation of strength of implementation of Malawi’s national family planning program at the health facility catchment area level. However, the best method for creating an index should be based on the pros and cons listed, not least, analyst capacity and ease of interpretability of findings. Ultimately, the resulting summary measure can aid decision-makers in understanding the combined effect of multiple aspects of programs being implemented in their health system and comparing the strengths of programs across geographies.
... Service responsiveness is conceptualized as the extent to which an individual's interaction with a specific health service fulfils a set of universally accepted ethical principles and nonclinical service standards (de Silva, 2000;Murray and Frenk, 2000;World Health Organization, 2000;Darby et al., 2003;Khan et al., 2021). According to the literature on the responsiveness and quality of FP services (Perera et al., 2011;2012a;2012b;RamaRao and Jain, 2016;Tessema et al., 2016;Jain and Hardee, 2018), both structural and behavioural domains of responsiveness are relevant to the integrated delivery of FP services. Structural domains include the ease of access, choice of provider, environment and the service continuity experienced by clients, whereas behavioural domains include the confidentiality, communication, dignity and the counselling afforded to clients. ...
Background
Evidence from several countries in sub-Saharan Africa suggests that the integration of family planning (FP) with childhood immunisation services can help reduce the unmet need for FP among postpartum women without undermining the uptake of immunisations. However, the quality and responsiveness of FP services that are integrated with childhood immunisations remain understudied.
Methods
A qualitative study was conducted in two districts of Malawi, which examined the factors influencing the responsiveness of FP services that were integrated with childhood immunisations in monthly public outreach clinics. Semi-structured interviews with clients (n=23) and FP providers (n=10), and a clinic audit were carried out in six clinics. Hardware (material) and software (relational) factors influencing service responsiveness were identified through thematic and framework analyses of interview transcripts, and clinic characteristics were summarised from the audit data to contextualise the qualitative findings.
Results
Overall, 13 factors were found to influence service responsiveness in terms of the ease of access, choice of provider, environment, service continuity, confidentiality, communication, dignity, and FP counselling afforded to clients. Among these factors, hardware deficiencies, including the absence of a dedicated building for the provision of FP services and the lack of FP commodities in clinics, were perceived to negatively affect service responsiveness. Crucially, the providers’ use of their agency to alter the delivery of services was found to mitigate the negative effects of some hardware deficits on the ease of access, choice of provider, environment and confidentiality experienced by clients.
Conclusions
This study contributes to an emerging recognition that providers can offset the effect of hardware deficiencies when services are integrated if they are afforded sufficient flexibility to make independent decisions. Consideration of software elements in the design and delivery of FP services that are integrated with childhood immunisations is therefore critical to optimise the responsiveness of these services.
... A better understanding of the responsiveness of FP services that are integrated with childhood immunisations could help inform the design and implementation of high quality integrated FP services that are clientcentred and rights-based [12,17]. Service responsiveness is concerned with whether the experience of an individual's interaction with a specific health service fulfils a set of 'legitimate' expectations or universally accepted ethical principles and non-clinical service standards [18][19][20][21][22]. ...
Background
Postpartum women represent a considerable share of the global unmet need for modern contraceptives. Evidence suggests that the integration of family planning (FP) with childhood immunisation services could help reduce this unmet need by providing repeat opportunities for timely contact with FP services. However, little is known about the clients’ experiences of FP services that are integrated with childhood immunisations, despite being crucial to contraceptive uptake and repeat service utilisation.
Methods
The responsiveness of FP services that were integrated with childhood immunisations in Malawi was assessed using cross-sectional convergent mixed methods. Exit interviews with clients (n=146) and audits (n=15) were conducted in routine outreach clinics. Responsiveness scores across eight domains were determined according to the proportion of clients who rated each domain positively. Text summary analyses of qualitative data from cognitive interviewing probes were also conducted to explain responsiveness scores. Additionally, Spearman rank correlation and Pearson’s chi-squared test were used to identify correlations between domain ratings and to examine associations between domain ratings and client, service and clinic characteristics.
Results
Responsiveness scores varied across domains: dignity (97.9%); service continuity (90.9%); communication (88.7%); ease of access (77.2%); counselling (66.4%); confidentiality (62.0%); environment (53.9%) and choice of provider (28.4%). Despite some low performing domains, 98.6% of clients said they would recommend the clinic to a friend or family member interested in FP. The choice of provider, communication, confidentiality and counselling ratings were positively associated with clients’ exclusive use of one clinic for FP services. Also, the organisation of services in the clinics and the providers’ individual behaviours were found to be critical to service responsiveness.
Conclusions
This study establishes that in routine outreach clinics, FP services can be responsive when integrated with childhood immunisations, particularly in terms of the dignity and service continuity afforded to clients, though less so in terms of the choice of provider, environment, and confidentiality experienced. Additionally, it demonstrates the value of combining cognitive interviewing techniques with Likert questions to assess service responsiveness.
... Quality of care (QoC) frameworks include implementation strength. In general, ISA fits into the Donabedian framework and its three dimensions of structure, process, and outcomes, and specifically for family planning, the Bruce-Jain framework divides QoC into six elements of FP programs [7][8][9]. Strength domains for this family planning (FP) assessment focus on the structural side of these frameworks, and include training, supervision, FP method choice and availability, demand generation activities, and accessibility [7]. ...
Background: Data that capture implementation strength can be combined in multiple ways across content and health system levels to create a summary measure that can help us to explore and compare program implementation across facility catchment areas. Summary indices can make it easier for national policymakers to understand and address variation in strength of program implementation across jurisdictions. In this paper we describe development of an index that we used to describe the district level strength of implementation of the Malawi national family planning program.
Methods: To develop the index, we used data collected during a 2017 national, health facility and community health worker Implementation Strength Assessment survey in Malawi to test different methods to combine indicators within and then across domains (4 methods: simple additive, weighted additive, principal components analysis, exploratory factor analysis) and combine scores across health facility and community health worker levels (2 methods: simple average and mixed effects model) to create a catchment area-level summary score for each health facility in Malawi. We explored how well each model captures variation and predicts couple years protection and how feasible it is to conduct each type of analysis and the resulting interpretability.
Results: We found little difference in how the four methods combined indicator data at the individual and combined levels of the health system. However, there were major differences when combining scores across health system levels to obtain a score at the health facility catchment area level. The scores resulting from the mixed effects model were able to better discriminate differences between catchment area scores compared to the simple average method. The scores using the mixed effects combination method also demonstrated more of a dose and response relationship with couple years protection.
Conclusions: The summary measure that was calculated from the mixed effects combination method captured the variation of strength of implementation of the Malawi national family planning program at the health facility catchment area level. However, the best method for creating an index should be based on pros and cons listed, not least, analyst capacity and ease of interpretability of findings. Ultimately, the resulting summary measure can aid decisionmakers in understanding the combined effect of multiple aspects of programs being implemented in their health system and comparing strengths of programs across geographies.
... Adapting this framework, we defined four domains of disrespectful care: poor clientcentered care, non-private consultations, refusal of care, and non-dignified care [31]. We conducted a desk review of existing quality of care indicators and assessment protocols that measured provider-delivered family planning care [26,[32][33][34][35][36][37][38]. 1 For each domain of the framework, we identified measurable indicators given the study design, used the questions from existing tools where they existed and developed new questions if needed (Table 1). For instance, for the poor client-center care domain, one indicator we measured was the proportion of visits where the provider did not ask the client preferred method. ...
Background
Provision of high-quality family planning (FP) services improves access to contraceptives. Negative experiences in maternal health have been documented worldwide and likely occur in other services including FP. This study aims to quantify disrespectful care for adult and adolescent women accessing FP in Malawi.
Methods
We used simulated clients (SCs) to measure disrespectful care in a census of public facilities in six districts of Malawi in 2018. SCs visited one provider in each of the 112 facilities: two SCs visits (one adult and one adolescent case scenario) or 224 SC visits total. We measured disrespectful care using a quantitative tool and field notes and report the prevalence and 95% confidence intervals for the indicators and by SC case scenarios contextualized with quotes from the field notes.
Results
Some SCs (12%) were refused care mostly because they did not agree to receive a HIV test or vaccination, or less commonly because the clinic was closed during operating hours. Over half (59%) of the visits did not have privacy. The SCs were not asked their contraceptive preference in 57% of the visits, 28% reported they were not greeted respectfully, and 20% reported interruptions. In 18% of the visits the SCs reported humiliation such as verbal abuse. Adults SCs received poorer counseling compared to the adolescent SCs with no other differences found.
Conclusions
We documented instances of refusal of care, lack of privacy, poor client centered care and humiliating treatment by providers. We recommend continued effort to improve quality of care with an emphasis on client treatment, regular quality assessments that include measurement of disrespectful care, and more research on practices to reduce it.
... (29) We conducted a desk review of existing quality of care indicators and assessment protocols that measured provider-delivered family planning care.(24, [30][31][32][33][34][35][36][b] For each domain of the framework, we identi ed measurable indicators given the study design, used the questions from existing tools where they existed and developed new questions if needed (table 1). For instance, for the poor client-center care domain, one indicator we measured was the proportion of visits where the provider did not ask the client preferred method. ...
Background Provision of high-quality family planning (FP) services improves access to contraceptives. Negative experiences in maternal health have been documented worldwide and likely occur in other services including FP. This study aims to quantify disrespectful care for adult and adolescent women accessing FP in Malawi.
Methods We used simulated clients (SCs) to measure disrespectful care in a census of public facilities in six districts of Malawi in 2018. SCs visited one provider in each of the 112 facilities: two SCs visits (one adult and one adolescent case scenario) or 224 SC visits total. We measured disrespectful care using a quantitative tool and field notes and report the prevalence and 95% confidence intervals for the indicators and by SC case scenarios contextualized with quotes from the field notes.
Results Some SCs (12%) were refused care because they did not agree to receive a HIV test or vaccination, or the clinic was closed during operating hours. Over half (59%) of the visits did not have privacy. The SCs were not asked their contraceptive preference in 57% of the visits, 28% reported they were not greeted respectfully, and 20% reported interruptions. In 18% of the visits the SCs reported humiliation such as verbal abuse.
Conclusions We documented instances of refusal of care, lack of privacy, poor client centered care and humiliating treatment by providers. We recommend continued effort to improve quality of care with an emphasis on client treatment, regular quality assessments that include measurement of disrespectful care, and more research on practices to reduce it.
Evidence suggests that integrating family planning (FP) services with childhood immunisations can increase postpartum contraceptive use by providing timely contact with FP services during the year following childbirth. However, little is known about clients' experiences of FP services within this context. Systems thinking was applied to examine the responsiveness of FP services that were integrated with childhood immunisations in routine outreach clinics across two districts of Malawi. A causal loop analysis of qualitative data captured through 1) structured exit interviews with clients (n=146) and 2) semi-structured interviews with clients (n=23) and their FP providers (n=10) was carried out to explain the system dynamics influencing the responsiveness of integrated FP services. Through this analysis, six feedback loops were identified as having a balancing effect on service responsiveness. Importantly, the clinic's client load was found to drive the responsiveness experienced by clients in the studied context. Overall, the results suggest that efforts to enhance the responsiveness of integrated FP services in outreach clinics should focus on 1) enhancing the providers' ability to alter the client flow in response to fluctuations in the clinic's client load, and 2) ensuring that an appropriate buffer of FP supplies is available in clinics to enable clients to consistently receive their preferred contraceptive irrespective of surges in demand. This study represents the first attempt at modelling the responsiveness of integrated FP services and its findings can be used to inform the design and delivery of FP services that are integrated with childhood immunisations in different settings.
Measuring quality of care in family planning services is essential for policymakers and stake-holders. However, there is limited agreement on which mathematical approaches are best able to summarize quality of care. Our study used data from recent Service Provision Assessment surveys in Haiti, Malawi, and Tanzania to compare three methods commonly used to create summary indices of quality of care-a simple additive, a weighted additive that applies equal weights among domains, and principal components analysis (PCA) based methods. The PCA results indicated that the first component cannot sufficiently summarize quality of care. For each scoring method, we categorized family planning facilities into low, medium, and high quality and assessed the agreement with Cohen's kappa coefficient between pairs of scores. We found that the agreement was generally highest between the simple additive and PCA rankings. Given the limitations of simple additive measures, and the findings of the PCA, we suggest using a weighted additive method.
Nearly three decades ago, Bruce articulated a client‐centered quality of care (QoC) framework for family planning services. The term quality has since then been used in many rights‐based frameworks for health, reproductive health, and family planning. This commentary compares the concept of quality used in many of these frameworks to reconcile the elements of the FP QoC framework with the use of quality in various rights frameworks. We propose five modifications to the original FP QoC framework to better align it with the treatment of quality in the rights‐based approaches and the way quality in family planning has been applied in practice.
Full text can be downloaded from Studies in Family Planning: http://dx.doi.org/10.1111/sifp.12052
