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Measurement that Matters: Understanding Quality of Care from Clients’ Perspectives

Despite the widely agreed importance of measuring quality of care (QoC), client perspectives are often missing from routine monitoring and studies. The Evidence Project has developed a package of validated, evidence-based tools and training materials to support governments and implementing partners in measuring and monitoring QoC. Measuring QoC from clients' perspectives will help programs celebrate successes, target areas for improvement, and ultimately improve uptake and continuation of voluntary contraceptive use.

High quality of care (QoC) in contraceptive provision is associated with greater contraceptive uptake, higher continuation of use, and improved client satisfaction. Over several decades, various frameworks and indicators to measure QoC have been developed, used, and updated. Across these frameworks, four key domains relating to care received are: respectful care, method selection, effective use, and continuity of contraceptive use and care. As these indicators evolve, programs have recognized the need to consider QoC from clients’ perspectives.

Measuring and monitoring QoC is critical for improving service provision and influencing provider behavior. It is also essential for understanding clients’ experiences, which in turn influences their satisfaction and contraceptive use. Measuring QoC from clients’ perspectives is the best way to understand what clients take away from the counseling and services they receive. Simply put, the key to understanding women’s experience is asking them. Yet, client perspectives are often missing from routine monitoring of QoC, despite the existence of validated QoC measures that can be easily and efficiently integrated into FP programs.

Indian women and children. Photo: Paula Bronstein/The Verbatim Agency/Getty Images
The Evidence Project validated two measures of quality of care using data from a longitudinal study of reversible contraceptive users in India. Photo: Paula Bronstein/The Verbatim Agency/Getty Images

Putting Measurement into Action

The Evidence Project, USAID’s flagship FP implementation science project led by the Population Council, validated two measures of QoC using data from a longitudinal study of reversible contraceptive users in Odisha and Haryana, India. Clients were interviewed about the QoC they received and we assessed the QoC measures’ ability to predict contraceptive continuation three months later. The QoC was measured using 22 items, which was reduced to a 10-item proxy measure through exploratory factor analysis. While the full 22-item measure more comprehensively captures clients’ experiences, a 10-item version adequately measures QoC and also predicts contraceptive continuation, making it ideal for routine data collection and monitoring of programs. We are currently working to confirm the same measures in an additional study in Burkina Faso, in order to routinely monitor QoC for FP services in the public sector and through performance-based financing programs.

We also validated a second way to measure QoC from clients’ perspectives, the MIIplus. The Method Information Index (MII), a three-item measure, has been used to assess QoC based on the information a client receives about a selected contraceptive method. As part of the above-mentioned study in India, we explored the value of adding a fourth, which asks whether the client was told about the possibility of switching to another method if the one she selected was not suitable. The addition of the fourth item, forming the MIIplus, was found to be a better predictor of contraceptive continuation than the MII alone. This short measure can be used to track progress in QoC at national and subnational levels.

A women in India receiving contraceptive medicine. Photo: Paula Bronstein /The Verbatim Agency/Getty Images
Monitoring client perspectives of quality of care allows programs to incorporate crucial feedback as they strengthen their service provision. Photo: Paula Bronstein /The Verbatim Agency/Getty Images

Supporting Use and Uptake

Despite the widely agreed importance of measuring QoC, client perspectives on QoC are often missing from routine monitoring and studies. To assist governments and implementing partners in measuring and monitoring QoC, we have developed a package of materials that includes:

  • Client exit interview tools in English and other languages
  • Data collection manual
  • Sample training agenda and presentation(s)

These resources can be used in multiple ways. For special studies, the full 22-item measure can be used to thoroughly assess QoC from client perspective. Analysis of these data can be done to confirm the shorter 10-item measure in contexts where it has not previously been used. If resources or interview length is more limited, the 10-item measure alone can be used for monitoring QoC. Additionally, the MIIplus can also be used as an abbreviated way to monitor QoC; however, it is not as comprehensive of a measure of QoC as the 10 or 22 item measures and only covers two of the four domains of QoC. MIIplus is currently being used at a national level in some national surveys, including DHS and PMA.

Why It Matters

With this body of work, we at the Evidence Project have shown that measuring the client’s perspective on the quality of FP services they receive can be done efficiently, with existing tools. Monitoring QoC from clients’ perspective allows programs and governments to identify areas of success and areas for improvement and to work toward the betterment of QoC in their programs. These measures provide tools for rigorous measurement of QoC received.

Key Takeaways

  • Validated, evidence-based tools and training materials to measure client perspectives on QoC exist and can be used in various contexts.
  • These measures can be inserted into routine measurement or studies.
  • Measuring QoC from clients’ perspectives will help programs celebrate successes, target areas for improvement, and ultimately improve client satisfaction with services and uptake and continuation of voluntary contraceptive use.
Indian women and children. Photo: Paula Bronstein/The Verbatim Agency/Getty Images
Leah Jarvis

Program Manager, Reproductive Health

Leah Jarvis, MPH is the Program Manager for Reproductive Health at the Population Council and works across a portfolio of reproductive health research programs, including maternal health, family planning, female genital mutilation/cutting, and more. Over the last decade, she has focused on monitoring, evaluation, and research in global public health programs, with a focus on sexual and reproductive health and rights. Her work at Planned Parenthood, EngenderHealth, and the Population Council has focused on expanding access to quality family planning programs for vulnerable populations in Latin America, Asia, and sub-Saharan Africa.

Katey Peck

Research Impact Specialist

Katey Peck, MPH is a Research Impact Specialist at the Population Council based in Washington, DC. She manages and provides technical input for a portfolio of dissemination and utilization activities designed to amplify the impact of the Council’s social, behavioral, and biomedical research. Through diverse experiences in the U.S. and global health fields, Katey has cultivated critical skillsets in research, policy, evaluation, and program management. Above all, she is committed to advancing sexual and reproductive health and rights and creating a more just world. She holds a BA in Health and Societies from the University of Pennsylvania and an MPH in Health Policy and Management from the University of Hawaiʻi at Mānoa. 

Sara Chace Dwyer

Staff Associate

Sara Chace Dwyer, MPH is a public health professional with a background in research, monitoring and evaluation, and program management. Sara is currently a Staff Associate at the Population Council and contributes to research activities aimed at improving family planning policies, programs, and practices worldwide. Sara is involved in implementation research looking at the quality of care in family planning services and ways to improve access to contraceptive services, including the potential role of private sector pharmacies and drug shops in family planning service delivery.  She has also worked at Jhpiego as a Program Officer for the Helping Mothers Survive Secretariat and managed program coordination for multiple maternal health and family planning projects. Sara received a Master of Public Policy from Georgetown University.

Erika Martin

Director of Research Impact

Erika Martin, MPH is Director of Research Impact at the Population Council and a long-time champion for translating research into practice to address critical health and development issues. Throughout her career, she has provided technical expertise to advance research utilization efforts with partners at national, regional, and global levels. Erika is a public health leader with over 15 years of experience in social sciences and operations research, program development and management, and use of evidence to strengthen reproductive health programs and health systems. Her professional experience extends across more than a dozen countries in Sub-Saharan Africa and Latin America, including several years based in Nairobi, Kenya.

Aparna Jain

Evidence Project Deputy Technical Director; Staff Associate II

Aparna Jain, PhD, MPH, has over 15 years of international public health experience. Aparna is the Deputy Technical Director of the Evidence Project and an Associate II at the Population Council, where she leads the design and implementation of research and evaluation studies in family planning and reproductive health. Her research areas focus on contraceptive use dynamics including determinants of contraceptive switching and continuation, measurement of quality of care, task sharing injectable contraceptives and implants to drug shops owners and private pharmacies, and mitigating the barriers to adolescents’ access to reproductive health services.

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