Women's Perspectives on Family Planning Service Quality: An Exploration of Differences by Race, Ethnicity and Language

CONTEXT: Despite calls to make family planning services more responsive to the values, needs and preferences of clients, few studies have asked clients about their experiences or values, and most have used surveys framed by researchers', rather than clients', perspectives.
METHODS: Forty in-depth interviews exploring lifetime experiences with and values regarding services were conducted with 18–36-year-old women who visited family planning clinics in the San Francisco Bay Area in 2007. Women were categorized as black, white, English- or Spanish-speaking Latina, or of mixed ethnicity to allow examination of differences by racial, ethnic and language group. Interviews were audiotaped, transcribed and coded thematically; matrices were then used to compare the themes that emerged across the subgroups.
RESULTS: Eight themes emerged as important to women's views of services: service accessibility, information provision, attention to client comfort, providers' personalization of care, service organization, providers' empathy, technical quality of care and providers' respect for women's autonomy. Women reported that it was important to feel comfortable during visits, to feel that their decision-making autonomy was respected, to have providers show empathy and be nonjudgmental, and to see the same provider across visits. The only notable difference among racial, ethnic and language groups was that Spanish-speaking Latinas wanted to receive language-appropriate care and contraceptive information.
CONCLUSIONS: Future surveys of family planning service quality should include measures of the factors that women value in such care, and efforts to improve providers' communication and counseling skills should emphasize the personalization of services and respect for clients' autonomy.     

IMAP statement on contraceptive counselling

Decisions regarding sexual and reproductive behavior involve biomedical, cultural, socioeconomic, and ethical considerations, and have a major impact upon personal and family life over both the long and short terms. Family planning service providers should therefore help their clients assess such issues, especially when permanent or long-term decisions are of issue. Contraceptive counselling is a two-way process of communication characterized by an exchange of information and views, discussion, and deliberation. Research demonstrates that contraceptive use improves when service delivery personnel listen and respond to clients' worries and concerns. Considerations should be given to the following issues when counseling clients on the use of contraception: the technical competence of the counselor and the quality of interaction with clients; tailoring counseling to meet clients' characteristics and needs, with priority given to discussing any issues the clients choose; encouraging useful discussion without overwhelming the client with information; gaining clients' confidence to help them voice personal concerns, yet not infringing upon their privacy; providing counseling in privacy; avoiding misunderstandings and the omission of important information or instructions; and not expecting clients to learn everything in one counseling session. Counseling should instead be supplemented by other means of education and information such as group sessions, posters, leaflets, and videos. Training in counseling, and counseling in special situations such with adolescents, perimenopausal women, postpartum and post abortion women, and women with medical disorders are discussed. A supplement to the statement focuses upon the social and health problems which arise when family planning services and sex education for adolescents are limited or absent.     

Smart patient, smart community: improving client participation in family planning consultations through a community education and mass-media program in Indonesia

In health care consultations, patients often receive insufficient information from providers and communicate little with providers about their needs or concerns. This study evaluated a combined community education and mass media intervention to improve clients' participation in family planning consultations. A household survey was conducted with 1,200 women in three sub-districts (two intervention and one control) of West Java province in Indonesia. A comparison of post-campaign findings among family planning clients suggests that the intervention as a whole had a positive effect on client participation, specifically the number of clients who prepared questions to ask the service provider prior to a family planning visit in the past year. Multivariate analyses showed that the "Smart Card" intervention and elements of the "Sahabat" (Friend) mass media campaign were positively associated with clients' preparation of questions and question asking behavior during family planning consultations, indicating that a combined community education and mass-media approach can improve client communication with providers and improve the quality of family planning counseling.     

Acceptability as a key determinant of client satisfaction: lessons from an evaluation of adolescent friendly health services in Mongolia

PurposeThe primary focus of this study is to investigate which characteristics of health service quality are most likely to determine client satisfaction with health services among adolescents in Mongolia.MethodsData were gathered from 1301 male and female clients. Exit interviews were used to measure client satisfaction; 82 clinics were visited. All clients between the ages of 10 and 19 years were asked to participate in the client exit interview; those who agreed to participate completed the questionnaire. Bivariate and multivariate analyses were conducted to determine significant associations between service satisfaction and the independent variables. All variables showing a significant bivariate association with service satisfaction (p ≤ .05) were retained for logistic regression analyses.ResultsThe strongest determinant to client satisfaction related to acceptability: adequate facility physical environment, receiving adequate information about the facility, and if the facility was private (i.e., other people didn’t know the services the client received). Additionally, clients who said they received some interruptions, either by other health workers or clients, were significantly less likely to be satisfied with the services.ConclusionsThis study demonstrates the importance of understanding and measuring different aspects of health service quality in defining client satisfaction. Although both accessibility and acceptability of services have been shown to be important in other studies, characteristics relating to acceptability emerged as critical in determining client satisfaction among adolescents in Mongolia. Efforts to improve health service delivery to adolescents need to understand and address the “adolescent friendly” characteristics that are most salient, and least fulfilled, in each particular context.     

改善计划生育服务和提高避孕方法满意度干预研究的中期评估

目的:评价成熟避孕方法的综合推广研究项目中期实施,了解干预后育龄妇女对计划生育服务和现用避孕节育方法满意度的影响。方法:2002年12月在重庆市和四川省分别选择一个经济和文化处于当地中等水平的县开展“成熟避孕方法的综合推广研究”,通过了解服务对象需求、服务提供、管理体制和避孕节育技术状况等内容,结合优质服务的理念,制订并逐步落实综合推广研究干预方案。2004年7月,进行研究现场中期评估。结果:干预后,育龄妇女对计划生育服务过程评价“较好”的比例从干预前的27．7％上升至61．0％;对现用避孕节育方法的满意程度从69．6％上升至79． 9％;现用避孕方法与意愿避孕方法的一致性从59．8％上升至84．2％。用多元Logistic回归调控潜在混杂因素后,育龄妇女对计划生育服务评价(OR=5．23,95％CI=2．95～9．29)、对现用避孕方法的满意程度(OR=1．98,95％CI=1．23-3．18)以及现用方法与育龄妇女意愿避孕方法的一致性均显著提高(OR=3．52,95％CI=2．14-5．79)。结论:干预措施能有效提高农村育龄妇女对计划生育服务和现用避孕方法的满意度,显著提高育龄妇女现用避孕方法与意愿避孕方法的一致性。     

深圳和眉山地区人工流产妇女对流产服务的评价及其比较

目的:评价深圳和眉山两地区不同部门和不同等级医疗机构人工流产服务质量,为进一步干预研究提供依据。方法:2005年10月~2006年3月,分别在深圳市和四川省眉山市对计划生育及卫生部门的市、县、乡三级开展人工流产服务机构,对完成流产手术离院前的妇女进行半结构式问卷调查,了解她们获得的相关服务及其对服务的评价。结果:术前医生对服务过程解释的比例为79%,术中对受术者不适进行处理的比例(61%),流产后避孕指导(67%)以及提供相应的宣教材料(52%)的水平均较低。深圳市流产服务在术后随访、性生活和避孕指导以及提供宣教材料方面高于眉山市,计划生育系统的人性化服务和流产后避孕服务好于卫生系统,县级机构术后指导和宣教以及人性化服务好于市级机构。总体上,流产妇女对服务的满意度为83%,其中对计划生育服务机构满意度(89%)高于卫生机构(76%),县级机构(93%)高于市级机构(72%)。结论:我国流产服务质量仍有很大的改善余地,尤其要加强以服务对象为中心的人性化服务和流产后避孕服务。经济欠发达地区和市一级服务机构是改进的重点。     

Goal attainment scaling: an effective outcome measure for rural and remote health services

ABSTRACT: The aim of this paper is to demonstrate the utility of Goal Attainment Scaling (GAS) as an effective, multidisciplinary measure of client outcomes for rural and remote health services. Goal Attainment Scaling was adopted by the Spinal Outreach Team (SPOT) as a client-focussed evaluation tool, as it is sensitive to the individual nature of clients' presenting issues and the multidisciplinary focus of the team. It enables individualised goals to be set on a five-point scale. Goal Attainment Scaling was introduced to the SPOT service after a pilot trial established guidelines for its effective implementation. An ongoing review process ensures that goal scaling remains realistic and relevant. Service outcomes can be effectively summarised using a frequency distribution of GAS scores. One of the important benefits of GAS is its facilitation of collaborative goal setting between clinician and client. Goal Attainment Scaling is recommended to rural and remote multidisciplinary health services because of its ability to summarise outcomes from heterogeneous service activities.     

Determinants of Quality of Family Planning Counseling among Private Health Facilities in Lagos

We use a unique dataset that includes an objective measure of the quality of family planning counseling from 927 private health facilities in Lagos State, Nigeria, to determine which variables at the facility and provider levels are most closely correlated with the quality of family planning counseling. Our data on quality come from mystery client surveys in which the clients posed as women seeking family planning counseling. We find that quality is strongly associated with the cadre of provider, with doctors delivering substantially higher‐quality counselling than nurses. Doctors not only outperform nurses overall, but also perform better on each category of quality and spend nearly three minutes longer on average counseling the mystery client. Location, fees charged for the service, and facility type are also strongly correlated with quality. The degree to which a facility specializes in family planning and facility size are only weakly predictive of quality.     

A client-centered approach to family planning: the Davao project

The reproductive health approach to family planning shifts the focus of service provision from macro-level demographic objectives to meeting clients' needs. Little field experience exists to date, however, to indicate how to implement this approach. This study describes a field project in Davao del Norte and Compostela Valley provinces in the Philippines that implemented the reproductive health approach on a quasi-experimental basis. The intervention was designed to address clients' self-defined reproductive needs by providing them with relevant and accurate information and services of good quality. It consisted of two components: Providers were trained in information exchange at fixed clinics, and supervisors were trained in facilitative supervision. The results presented here indicate that the client-centered intervention was successful in enhancing service providers' knowledge and improving the content of information exchange between providers and clients. One provincial health officer has expanded the intervention throughout his province, while other provinces are interested in duplicating the model.     

Indigenous perceptions and quality of care of family planning services in Haiti

This paper presents a method for evaluating and monitoring the quality of care of family planning services. The method was implemented in Haiti by International Planned Parenthood Federation Western Hemisphere Region (IPPF/WHR), the managerial agency for the Private Sector Family Planning Project (PSFPP), which is sponsored by the USAID Mission. The process consists of direct observations of family planning services and clinic conditions by trained Haitian housewives playing the role of 'mystery clients', who visit clinics on a random basis without prior notice. Observations conducted by mystery clients during one year, from April 1990 to April 1991, are presented and illustrate the use of the method. In addition, measurements for rating the acceptability of the services were developed, providing a quantitative assessment of the services based on mystery clients' terms. Statistical results demonstrate that simulated clients ranked some criteria of acceptability higher than others. These criteria are: the interaction provider/client, information adequacy, and competence of the promoter. Likewise, simulated clients' direct observations of the services permitted the identification of deficiencies regarding the quality of care such as the paternalistic attitudes of the medical staff; the lack of competence of promoters; and the lack of informed choice. Based on its reliability since its implementation in 1990 the method has proven to be a useful tool in programme design and monitoring.     

The health workers for change impact study in Kenya

This paper reports the detailed results of a study of the impact of the Health Workers for Change (HWFC) workshop series on clients' perceptions of health services, relationships within the health centre and relations between the health facility and the district health system. The study was carried out in three stages: baseline, intervention and evaluation over a period of 20 months. Data, both qualitative and quantitative, were collected at three levels: client, facility and system. Results indicate that relations between health workers and clients improved a great deal after the intervention while those between the facility and the system remained to a large extent unchanged. The paper concludes that, with external support and help, especially from the health system level, health workers can work towards improving health services and their job satisfaction, which can lead to better health worker-client relations.     

Client satisfaction in support of service planning within a regulatory framework: experience of a research hospital

Research Operations at UHN provide services to a large, complex client research community with varying needs. This requires complex coordination and continual refining of service and resource targets to meet client, government and external stakeholder requirements. The UHN Research Operations model focuses on six key enablers: client education, service team expertise, direct communication, process improvement, quality assurance, and, systems and tools. Service departments that have deployed these enablers experience improved client satisfaction.     

A REVIEW OF HEALTH INTERPRETER SERVICES IN A RURAL COMMUNITY: A TOTAL QUALITY MANAGEMENT APPROACH

ABSTRACT: The current focus in health care is on total quality management (TQM), a process that involves ongoing quality improvement and benefits both internal and external customers. In order to comply with the values of TQM, the Griffith Murrumbidgee Health Service set up a team to review the use of interpreters in a healthcare setting. Staff from a number of wards/units filled out a survey sheet regarding interpreter services for each patient/client presenting for service during a 1-month period. The results showed that (i) there was a marked tendency by staff to use non-accredited interpreters; and (ii) staff who used non-accredited interpreters tended to inappropriately assess patient/client interpreting needs and to be unfamiliar with the Health Care Interpreter Policy. The TQM team subsequently devised several strategies for change.     

Family planning hotline

Since last March, a family planning hotline has been putting the caller in touch with the Family Planning Information Service. This is possibly the 1st centralized referral and information service for family planning in any major city in the U.S. Each months this fall 1400 New Yorkers called the hotline number to obtain information about family planning, infertility, abortion, and voluntary sterilization. Several major parallel developments made the creation of the Family Planning Information Service possible and strengthened its changes of success. The service is headed by a registered nurse who is assisted by 2 specially trained nonprofessional staff members. The unit is housed in Planned Parenthood's Manhattan headquarters. The Service has a special telephone number which is listed in all telephone directories. A number of promotional devices have been used to build and maintain the volume of inquiries. The results of the intensive work to develop and maintain the service have been dramatic. From a monthly volume of 300 calls in March, the figure in May had reached 670. In July there were 962 inquiries and in October the figure rose to 1421. About 90% of these calls are from women. By far the largest number of requests for information have concerned contraception and where such services can be obtained. Over 200 calls have been inquires about infertility problems, and 361 calls have concerned abortion. More than 100 calls have been about sterilization, with men outnumbering women 2:1.     

Development of a Person‐Centered Family Planning Scale in India and Kenya

Despite recognition that person‐centered care is a critical component to providing high quality family planning services, there lacks consensus on how to operationalize and measure it. This paper describes the development and validation of a person‐centered family planning (PCFP) scale in India and Kenya. Cross‐sectional data were collected from 522 women in Kenya and 225 women in India who visited a health facility providing family planning services. Psychometric analyses, including exploratory factor analysis, were employed to assess the validity and reliability of the PCFP scale. Separate scales were developed for India and Kenya due to context‐specific items. We assessed criterion validity by examining the association between PCFP and global measures of quality and satisfaction with family planning care. The analysis resulted in a multidimensional PCFP scale, including 20 items in Kenya and 22 items in India. Through iterative factor analysis, two subscales were identified for both countries: “autonomy, respectful care, and communication” and “health facility environment.” This scale may be used to evaluate quality improvement interventions and experiences of women globally to support women in achieving their reproductive health goals.     

Service provider perspectives on post-abortion contraception in Nepal

The government of Nepal has articulated a commitment to the provision of post-abortion contraception since the implementation of a legal safe abortion policy in 2004. Despite this, gaps in services remain. This study examined the perspectives of abortion service providers and administrators regarding strengths and shortcomings of post-abortion contraceptive service provision. In-depth interviews were conducted with 24 abortion providers and administrators at four major health facilities that provide legal abortion in Nepal. Facility factors perceived to impact post-abortion contraceptive services included on-site availability of contraceptive supplies, dedicated and well-trained staff and adequate infrastructure. Cultural norms emerged as influencing contraceptive demand by patients, including method use being unacceptable for women whose husbands migrate and limited decision-making power among women. Service providers described their personal views on appropriate childbearing and the use of specific contraceptive methods that influenced counselling. Findings suggest that improvements to a facility’s infrastructure and training to address provider biases and misinformation may improve post-abortion family planning uptake. Adapting services to be sensitive to cultural expectations and norms may help address some barriers to contraceptive use. More research is needed to determine how to best meet the contraceptive needs of women who have infrequent sexual activity or who may face stigma for using family planning, including adolescents, unmarried women and women whose husbands migrate.     

Clients’ Perceptions of Service Quality and Satisfaction at Their Initial Title X Family Planning Visit

Family planning service quality and clients’ satisfaction with services are important determinants of clients’ contraceptive use and continuation. We examine women’s experiences at family planning clinics on a range of dimensions, including patient-centered communication (PCC), and identify experiences associated with higher ratings of service quality and satisfaction. New female clients (n = 748), ages 18–35 years, from clinics in three major metropolitan areas completed computer-administered interviews between 2008 and 2009. Factors associated with primary outcomes of service quality and satisfaction were assessed using multinomial and ordinary logistic regression, respectively. Higher scores on a Clinician–Client Centeredness Scale, measuring whether clinicians were respectful, listened, and provided thoughtful explanations, were associated with perceptions of good quality care and being very satisfied. Higher scores on a Clinic Discomfort Scale, measuring staff and waiting-room experiences, were associated with reduced satisfaction. Clients’ interactions with clinicians, especially PCC, influence their perceptions of service quality, whereas their satisfaction with services is also influenced by the facility environment. These measures are adaptable for agencies to identify the factors contributing to their own clients’ satisfaction–dissatisfaction with care and perceptions of service quality.     

Is permanent contraception acceptable in sub-Saharan Africa?

Some authors contend that the low use of family planning in sub-Saharan Africa is due to a low demand for fertility regulation among African men and women. The present authors' experience in Africa has been that it is not the demand for family planning services, but the way services are delivered that accounts for low numbers of acceptors in Africa. The specific case of Kenya is mentioned, where improvements in the quality of sterilization services and increases in the number of institutions that can provide minilaparotomy under local anesthesia have led to an increase in the acceptance of sterilization. The authors maintain that the demand for all family planning methods does exist, and it is up to the donor agencies and family planning service providers to try to meet that demand by providing services that are efficient to providers while oriented to the clients' needs. In the case of voluntary surgical contraception, that means providing minilaparotomy under local anesthesia.     

贫困农村妇女生殖道感染服务提供与利用研究

目的：分析贫困农村妇女对生殖道感染服务的利用以及服务提供情况。方法：采用问卷调查，体检调查，个人深入访谈和小组集中讨论会等定量和定性研究方法。结果：乡级卫生机构资源利用不合理，村卫生室设备及人员均缺乏，个体诊所必需的诊断设备缺乏；贫困农村妇女对生殖道感染服务需要高，但利用率低，经济困难、生殖道感染知识缺乏、传统观念的束缚以及服务质量低下是影响妇女利用生殖道感染诊治服务的主要原因。结论：提高妇女对RTIs服务的可及性；建议对基层服务提供者加强业务培训；对妇女进行生殖道感染知识的健康教育。