Abstract
Objective
Study design
Results
Conclusion
Implications
Keywords
1. Introduction
Crossing the quality chasm: a new health system for the 21st century | The BMJ [Internet]. [Available from: https://www.bmj.com/content/323/7322/1192.1.full. Accessed November 19, 2021
“Measuring quality of care: A review of previously used methodologies a” by Katherine Tumlinson [Internet]. Available from: https://knowledgecommons.popcouncil.org/departments_sbsr-rh/679/. Accessed August19, 2021
Understanding quality of contraceptive services from women's perspectives in Gujarat, India: a focus group study | BMJ Open [Internet]. Available from: https://bmjopen.bmj.com/content/11/10/e049260.abstract. Accessed November 19, 2021
2. Material and methods
2.1 Data source
2.2 QCC scale overview
Understanding quality of contraceptive services from women's perspectives in Gujarat, India: a focus group study | BMJ Open [Internet]. Available from: https://bmjopen.bmj.com/content/11/10/e049260.abstract. Accessed November 19, 2021
Item abbrev-iation | Item | Item consistent across countries (Y/N) | # votes (max = 5) | Factor loading: QCC-Mexico (22 items total) | Factor loading: QCC-Ethiopia (26 items total) | Factor loading: QCC-India (23 items total) | Key reason selected or not selected for QCC-10 | |
---|---|---|---|---|---|---|---|---|
QCC Construct: Information Exchange | ||||||||
1 | opinion | During the contraception consultation, I was able to give my opinion about what I needed. | Y | 4 | 0.4-0.6 | 0.51 | 0.72 | Selected: High number of votes |
2 | personal | The provider asked me questions in order to provide counseling that fit my personal experience. | N d This item was added to the QCC Scale for Ethiopia and India based on formative research suggesting this is an important element of quality related to Information Exchange; this item was not fielded in Mexico. In India the wording was modified for clarity, based on cognitive interviews, to read “The provider asked me personal questions …”. | 3 | N/A | 0.63 | 0.63 | Selected: Concept of personalized counseling key component of QCC construct |
3 | info | I received complete information about my options for contraceptive methods. | Y | 2 | 0.6–0.7 | 0.51 | 0.42 | Selected: Concept of information receipt key component of QCC construct |
4 | explain | The provider knew how to explain contraception clearly. | N | 0 | 0.6–0.8 | 0.64 | N/A | Not selected: Performed poorly in India, no votes |
5 | opportunity | I had the opportunity to participate in the selection of a method. | Y | 2 | 0.4–0.6 | 0.56 | 0.18 | Not selected: Performed poorly in India |
6 | sti_info | I received information about how to protect myself from sexually transmitted infections. | Y | 2 | 0.5 | 0.49 | 0.62 | Not selected: STI information receipt not central to QCC construct |
7 | method_fail | I received information about what to do if a method fails (e.g., broken condom, forget a pill, forgot injection appointment, feel an IUD is poorly placed) | Y | 3 | 0.6–0.7 | 0.73 | 0.60 | Not selected: item less relevant for clients who do not select a method |
8 | body_react | I could understand how my body might react to using contraception. | Y | 2 | 0.7–0.8 | 0.76 | 0.60 | Selected: Concept of side effect understanding central to QCC construct |
9 | method_use | I could understand how to use the method(s) we talked about during the consultation. | Y | 2 | 0.6–0.8 | 0.74 | 0.49 | Selected: Concept of understanding method use central to QCC construct |
10 | method_react | The provider explained to me what to do if I had a reaction to a method (e.g., allergies, nausea, pains, menstrual changes). | Y | 3 | 0.7 | 0.74 | 0.65 | Not selected: item less relevant for clients who do not select a method |
11 | method_stop | I received information about what to do if I wanted to stop using a method. | Y | 1 | 0.6–0.7 | 0.74 | 0.47 | Not selected: item less relevant for clients who do not select a method |
QCC Construct: Interpersonal Relations | ||||||||
12 | info_private | I felt the information I shared with the provider was going to stay between us. | Y | 3 | 0.6–0.7 | 0.56 | 0.14 | Not selected: Performed poorly in India |
13 | enough_time | The provider gave me the time I needed to consider the contraceptive options we discussed. | Y | 3 | 0.5–0.8 | 0.68 | 0.58 | Selected: Concept of informed decision-making central to QCC construct |
14 | prov_friendly | The provider was friendly during the contraception consultation. | N | 2 | 0.8 | 0.65 | N/A | Not selected: Performed poorly in India |
15 | prov_knows | I felt the health care provider had sufficient knowledge about contraceptive methods. | N | 0 | 0.8 | 0.70 | N/A | Not selected: Performed poorly in India, no votes |
16 | prov_health | The provider showed interest in my health while we talked about contraception. | Y | 1 | 0.8 | 0.66 | 0.56 | Not selected: items 1 and 18 are similar and received more votes |
17 | prov_opinion | The provider was interested in my opinions. | Y | 1 | 0.8 | 0.73 | 0.62 | Not selected: items 1 and 18 are similar and received more votes |
18 | express_self | I felt encouraged to ask questions and express my concerns. | N | 4 | N/A | 0.75 | 0.68 | Selected: High number of votes |
19 | prov_listens | I felt listened to by the provider. | Y | 1 | 0.7–0.8 | 0.70 | 0.59 | Not selected: items 1 and 18 are similar and received more votes |
20 | no_interrupt | The provider made efforts to ensure there were no interruptions during our session. | N | 1 | N/A | 0.50 | 0.64 | Selected: Concept of privacy is central to the QCC construct |
QCC Construct: Disrespect and Abuse | ||||||||
21 | prov_insist | The health care provider pressured me to use the method they wanted me to use. | Y | 5 | 0.6 | 0.02 | 0.14 | Selected: high number of votes; despite low loadings in Ethiopia and India, absence of coercion is central to QCC construct |
22 | prov_judge | I felt the provider treated me poorly because they tend to judge people. (Clothing, age, living condition, marital status, etc.) | Y | 0 | 0.7–0.8 | 0.46 | 0.43 | Not selected: No votes |
23 | scold_age (or scold_use, in India) | I felt scolded because of my age. | N g In India, this item was replaced with “I felt scolded because of the way I was using contraception” based on formative research suggesting the importance of social norms around what contraceptives are acceptable to be used depending on the number of children someone has and the greater salience of this potential dimension of discrimination compared to age discrimination | 0 | 0.5 | 0.60 | 0.54 | Not selected: No votes |
24 | prov_sexlife | The provider made me feel uncomfortable because of my sex life (e.g., when I started having sex, my sexual preferences, the number of partners I have, the number of children I have). | Y | 2 | 0.7–1.0 | 0.61 | 0.96 | Not selected: item deemed too long and less central to QCC construct than item 26 which is also focused on discrimination |
25 | prov_touched | The provider touched me or looked at me in a way that made me feel uncomfortable. | Y | 1 | 0.3–0.8 | 0.58 | 0.86 | Not selected: this item received lower votes than other Disrespect and Abuse subscale items |
26 | scold_marital | I felt scolded because of my marital status. | N | 2 | N/A | 0.72 | 0.93 | Selected: discrimination is a central component of QCC construct |
2.3 Item reduction process
2.4 Descriptive and psychometric analysis of reduced scale
2.5 Convergent validity assessment
3. Results
3.1 Item reduction
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3.2 Descriptive and psychometric analysis of reduced scale
Item abbreviation | Mean/standard deviation (SD) | Exploratory factor analysis (EFA) factor loading | Item-rest correlations | |||||||
---|---|---|---|---|---|---|---|---|---|---|
Mexico (N = 499) | Ethiopia (N = 599) | India (N = 313) | Mexico | Ethiopia | India | Mexico | Ethiopia | India | ||
1 | opinion | 3.5 (0.6) | 3.3 (0.6) | 3.4 (0.5) | 0.5 | 0.6 | 0.8 | 0.4 | 0.5 | 0.6 |
2 | personal | N/A | 3.1 (0.6) | 3.3 (0.6) | N/A | 0.6 | 0.6 | N/A | 0.6 | 0.5 |
3 | info | 3.5 (0.7) | 2.4 (0.8) | 3.4 (0.5) | 0.7 | 0.5 | 0.4 | 0.7 | 0.4 | 0.3 |
4 | body_react | 3.3 (0.8) | 2.9 (0.7) | 3.2 (0.6) | 0.7 | 0.7 | 0.6 | 0.6 | 0.6 | 0.5 |
5 | method_use | 3.4 (0.7) | 3.0 (0.6) | 3.3 (0.5) | 0.7 | 0.7 | 0.5 | 0.6 | 0.6 | 0.3 |
6 | enough_time | 3.5 (0.6) | 3.0 (0.6) | 3.3 (0.5) | 0.7 | 0.7 | 0.6 | 0.6 | 0.6 | 0.4 |
7 | express_self | N/A | 2.9 (0.7) | 3.0 (0.7) | N/A | 0.6 | 0.6 | N/A | 0.6 | 0.4 |
8 | no_interrupt | N/A | 3.0 (0.7) | 3.2 (0.7) | N/A | 0.5 | 0.6 | N/A | 0.4 | 0.3 |
9 | prov_insist | 3.9 (0.6) | 3.6 (0.4) | 3.0 (1.3) | 0.2 | 0.1 | 0.4 | 0.2 | 0.1 | -0.4 |
10 | scold_marital | N/A | 4.0 (0.2) | 3.9 (0.4) | N/A | 0.3 | 0.1 | N/A | 0.2 | <0.1 |
Overall scale | 3.5 (0.5) | 3.1 (0.4) | 3.3 (0.3) | |||||||
Cronbach's alpha b A sensitivity analysis examining scale properties without the scold_marital item revealed no change in alpha or factor loadings for other items in India or Ethiopia. Removing both scold_marital and prov_insist did not change item or scale properties in Ethiopia, but improved the alpha in India to be comparable to Ethiopia and Mexico (0.8) and increased the info factor loading in India to 0.5. | 0.8 | 0.8 | 0.5 |
3.3 Convergent validity
N (%) | OR (95% CI) | |||||
---|---|---|---|---|---|---|
Mexico | Ethiopia | India | Mexico | Ethiopia | India | |
Highest overall rating of experience with provider b Missing data ranged from 1 in Ethiopia to 3 in Mexico; no data were missing in India. We conducted a sensitivity analysis to examine the relationship of an 8-item version of the scale, removing the two negatively worded items that capture disrespect and abuse (prov_insist and scold_marital) and that were less commonly endorsed among participants, and found scores remained highly correlated with the client experience measure (Mexico: OR = 7.0, 95% CI = 4.2–11.8; Ethiopia: OR = 30.7, 95%CI = 15.4–60.9; India: OR = 3.2, 95% CI = 1.5–6.7).3 We did not examine this outcome in India because participants were interviewed within two weeks of their visit, with those initiating method use prioritized for recruitment. Missing data ranged from 104 in Mexico to 122 in Ethiopia due to some women not having selected a method during their visit in Mexico and Ethiopia. A sensitivity analysis removing prov_insist and scold_marital did not meaningfully change the finding (Mexico: OR = 2.4, 95% CI = 1.3–4.2; Ethiopia: OR=2.3, 95% CI = 1.6–3.2). | 250(50.4%) | 163(27.3%) | 152(48.6%) | 10.6(5.7-19.6) | 45.5(23.6–87.7) | 4.4(1.8–11.0) |
Intention to use method selected at baseline3 | 361(91.4%) | 314(65.3%) | N/A | 3.3(1.7-6.4) | 3.5(2.5–4.9) | N/A |
4. Discussion
Understanding quality of contraceptive services from women's perspectives in Gujarat, India: a focus group study | BMJ Open [Internet]. Available from: https://bmjopen.bmj.com/content/11/10/e049260.abstract. Accessed November 19, 2021
Understanding quality of contraceptive services from women's perspectives in Gujarat, India: a focus group study | BMJ Open [Internet]. Available from: https://bmjopen.bmj.com/content/11/10/e049260.abstract. Accessed November 19, 2021
Appendix. Supplementary materials
References
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Footnotes
☆Data availability: Data will be available on Dryad.
☆☆Declaration of Competing Interest: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
☆☆☆Funding disclosures: This work was supported by the David and Lucile Packard Foundation [Grant number: #2018-67680].
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