High-quality contraceptive counseling and services must take a person-centered approach, placing a high value on women and girls’ individual preferences, goals, and rights. Person-centered care in family planning and reproductive health services includes an emphasis on autonomy and decision-making, compassionate communication, dignity and respect, and patient needs assessment. Poor quality care negatively impacts method satisfaction, undermines client autonomy, and erodes trust in the health system. However, quality of contraceptive care is often measured as simple client satisfaction scores. When asked, most clients report high satisfaction on such measures. And these simple scores produce very little in the way of actionable insights, leaving programs in the dark about where their care is falling short or what could be done to improve the quality of services.
To improve the quality of contraceptive care, researchers have developed broad client experience of care (CEC) measures that assess patient/provider communication, respect, autonomy, and informed choice (among other factors) in sexual and reproductive health programming. However, new contraceptive methods like depot medroxyprogesterone acetate-subcutaneous (DMPA-SC) self-injection introduce components of care that aren’t well-captured by existing general contraceptive CEC measures. Factors like opportunities to practice self-injection technique, preparedness and confidence to self-administer, and opportunities to ask questions are critical to ensuring high-quality self-injection service delivery and need to be captured in a more specific CEC measure. It would also be programmatically useful to have a CEC measure that could compare client experience between those self-injecting and those receiving provider-administered DMPA-SC.
We developed a metric that could be used to assess CEC for self-injected and provider-administered DMPA-SC in Malawi. Our research, described here in Studies in Family Planning, included a literature review of existing person-centered care and CEC metrics in the family planning and sexual and reproductive health space, in-depth interviews with women of reproductive age in Lilongwe, Malawi, cognitive interviews with similar women to validate the quantitative survey instrument, and a quantitative survey of women 18–49 years old who had received DMPA-SC (either self-injected or provider-administered) from a study facility in the previous three months. Based on the findings from the literature review and in-depth interviews, we developed an initial CEC survey that comprised 97 items across 13 domains. Domains included dignity and respect, autonomy, privacy/confidentiality, communication, emotional supportive care, trust, health facility environment, choice, cost, safety, awareness, confidence, and empowerment. Following field testing and cognitive interviewing of the translated tool, this was reduced to 54 items. The 54-item version of the survey was then administered to 400 DMPA-SC clients in public and private sector facilities in Lilongwe, including 198 self-injecting clients and 202 receiving provider-administered DMPA-SC.
We analyzed data from the client exit interviews using psychometric analyses (described in more detail in our paper). Ultimately, we dropped 36 items from our analysis due to low variability, collinearity, high uniqueness, or insufficient factor loading. Half of these items were dropped because more than 90% of women gave the same answer. Nearly all women reported feeling safe at the facility where they received DMPA-SC, receiving the method they wanted, not feeling pressured to choose DMPA-SC, being treated with care and friendliness by staff, and feeling their information would be kept confidential. While these factors are important dimensions of care, they were unable to distinguish one woman’s experience from another’s in our context.
Psychometric analysis resulted in an 18-item set across two factors: empowerment (largely based on an existing, validated Self-Efficacy Scale) and client experience of care. Ultimately our CEC measure retained seven domains that the women we interviewed and the literature had identified as important to experience of care, including empowerment, trust, agency, communication, dignity and respect, choice, and emotionally supportive care. Reliability for the resulting CEC scale was low-to-moderate (Cronbach’s alpha = 0.68), which likely reflects the breadth of domains included, rather than problems with any one item (though test-retest assessment and confirmatory factor analysis in other settings/populations would strengthen our confidence in it).
We also used regression modeling to compare CEC between DMPA-SC self-injection users and provider-administered users, adjusting for factors such as facility type, first-time injection, and demographic characteristics. While we did not find any difference in empowerment scores between women receiving provider-administered DMPA-SC and those self-injecting, we did find a significant positive association between CEC and self-injection. Self-injecting clients scored about 1.2 points higher on the eight-item CEC scale than those receiving DMPA-SC from a provider, after adjusting for covariates and empowerment score.
While this metric will need further psychometric assessment in other contexts and populations, this CEC scale provides an important opportunity to measure client experiences when accessing DMPA-SC, including when choosing between self-injection and provider-administered options. Because most women self-injecting in our study had injected at the health facility (rather than at home), additional research is also needed on the client experience of care for women receiving take-home doses, and to explore whether the differences in CEC between users of provider-administered and self-injected DMPA-SC was driven by, for example, appointment intensity. Contraceptive self-injection has the potential to increase family planning access and to give women greater agency over their reproductive health. However, achieving this will depend on high-quality counseling and service delivery. We hope this CEC measure will allow health systems and implementers to better monitor CEC within injectable contraceptive services, and to generate actionable insights that can improve women’s experiences.
About the Authors
Erica Felker-Kantor, Population Services International
Eden Demise, Population Services International
Philip Mkandawire, Family Health Services Malawi
Claire Rothschild, Population Services International
Kristen Little, Population Services International