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.
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.
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.
- 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.