The quality of family planning services in the United States: findings from a literature review

Quality of Care is Perceived to be High with Community-based Antiretroviral Therapy (ART) Services for Female Sex Workers in Tanzania: Qualitative Findings from a Pilot Implementation Science Study

This qualitative study reports on female sex workers' (FSWs) perceptions of the quality of antiretroviral therapy (ART) services they received as part of a community-based ART distribution intervention compared to services received by FSWs in the standard of care (SOC) arm. In-depth interviews were conducted with 24 participants to explore their perceptions of the quality of ART services. Data was analyzed using a quality-of-care framework that included but was not limited to, domains of accessibility, effective organization of care, package of services, and patient-centered care. Overall, FSWs in the intervention arm reported community-based ART services to be highly accessible, organized, and effective, and they highly valued the patient-centered care and high level of privacy. Community-based ART programs for FSWs can have high quality-of-care, which can have a positive effect on HIV treatment outcomes for FSWs.

Evaluating the MyPath web-based reproductive decision support tool in VA primary care: Protocol for a pragmatic cluster randomized trial

BACKGROUND

Counseling to identify and support individuals' desires for family formation is a key component of preventive health care that is often absent in primary care visits. This study evaluates a novel, web-based, person-centered intervention to increase the frequency and quality of communication about reproductive goals and healthcare needs in Veterans Health Administration (VA) primary care.

METHODS

We describe a hybrid type 1 effectiveness-implementation cluster randomized controlled trial in seven VA healthcare systems testing a web-based reproductive health decision support tool (MyPath). VA primary care providers are enrolled and randomized to intervention or usual care arms. Veterans scheduled to see intervention-arm providers receive a text message inviting them to use MyPath ahead of their appointment; Veterans scheduled to see control-arm providers receive usual care. Target enrollment is 36 providers and 456 Veterans. Outcomes are assessed by Veteran self-report after the visit and at 3- and 6-months follow-up. The primary outcome is occurrence of reproductive health discussions involving shared decision making; secondary outcomes include measures of communication, knowledge, decision conflict, contraceptive utilization, and receipt of services related to prepregnancy health. Data on implementation barriers, facilitators and cost are collected.

RESULTS

The trial is ongoing with no results to report. We have enrolled 36 primary care providers across 7 VA healthcare systems and recruitment of Veterans is ongoing.

CONCLUSIONS

Results will inform efforts to increase the quality and person-centeredness of reproductive healthcare delivery in primary care and to operationalize and scale up use of digital decision support tools in clinical settings.

TRIAL REGISTRATION

http://ClinicalTrials.gov Identifier: NCT04584294 Trial Status: Recruiting.

Assessment of Family Planning Counseling Provided for Postpartum Women and Associated Factors

Background

Good quality family planning counseling particularly in the postpartum period is paramount to contraception adoption and continuation; it is also paramount in the reduction of maternal as well as infant morbidity and mortality.

Objective

Assess the level of family planning counseling provided for women in their immediate postpartum period in the labor ward at Saint Paul's Hospital in 2019.

Method

An institution-based cross-sectional study was conducted from February to March of 2019 among women in the labor ward. A face-to-face exit interview was conducted with 209 randomly selected women. A structured pretested questionnaire was used to assess the level of family planning counseling provided. Bivariate logistic regression was used to test for statistical association.

Results

Only 28.2% of the counseling sessions were adequate. Most (58.9%) of the counseling sessions did not maintain the privacy of the client. In 67.9% of the sessions, the counselor did not ask the concern of the client regarding the use of modern family planning methods and 74.2% of the clients were not told about the possible side effects of a method. Clients with no formal education (OR = 2.52, 95%CI = 1.1‐3.3) and those with only primary level education (OR = 1.22, 95%CI = 1.04‐3.02) were more likely to have had inadequate counseling.

Conclusion

The level of family planning counseling was inadequate. The study indicated the need to provide training for service providers on family planning counseling with the existing standard frameworks but also in consideration of the sociodemographic background of the client, particularly their educational status.

Patient-provider communication before and after implementation of the contraceptive decision support tool My Birth Control

OBJECTIVE

To compare differences in patient-provider communication among patients who, prior to contraceptive counseling, used or did not use a decision support tool ("My Birth Control") which has educational and interactive modules and produces a provider printout with the patient's preferences.

METHODS

As part of a cluster-randomized trial of the tool in four San Francisco safety net clinics, we collected and thematically analyzed 70 audio recordings of counseling visits (31 pre- and 39 post-tool implementation) from 15 providers randomized to the intervention.

RESULTS

Without the tool, most providers began by asking participants what method they were considering and focused counseling on that method or on directing patients towards long-acting reversible contraception; with the tool, most focused on reviewing and discussing multiple methods of interest to the participant as indicated on the printout. Discussion of patients' preferences for specific method features was not observed in pre-implementation recordings but was part of several post-implementation recordings. Several participants explicitly noted they had gained knowledge from the tool.

CONCLUSION

Observed counseling differences suggest the tool may have a positive impact on patient-centeredness of contraceptive counseling, consistent with findings from the main study.

PRACTICE IMPLICATIONS

My Birth Control shows potential for improving patient-centeredness in counseling without extensive provider training.

Comparing simulated client experiences with phone survey self-reports for measuring quality of information given in family planning counseling: The case of depot medroxyprogesterone acetate – subcutaneous (DMPA-SC) in Nigeria

Background: The quality of family planning services can have important implications for uptake and continued method use. The aim of this analysis is to examine aspects of quality related to information provided for a new injectable contraceptive method, DMPA-SC (depot medroxyprogesterone acetate – subcutaneous, known as Sayana Press®), service provision and contraceptive services more broadly in Nigeria. Methods: We compared self-reports from follow-up phone surveys with users to simulated client interactions that were designed to measure the same concepts. Through mixed-methods, we sought to more deeply understand the biases associated with different data collection methods that ultimately lead to different conclusions regarding quality of information provided in contraceptive services, and to further assess to what extent these methods were suitable for detecting differences in quality across sub-groups using the case of married versus unmarried women. Results: We found that simulated clients reported lower levels of informational quality across all comparable quality indicators than phone survey respondents attending the same facilities. Both methods were able to detect differential treatment by marital status. Conclusions: A mixed-methods approach can provide differential insights into informational quality of family planning services, especially when aiming to understand both objective and subjective aspects of quality.

Examining Women's and Men's Ideal Criteria Before Forming Families

In the United States, family formation decision-making is more complex than the predominant models that have been used to capture this phenomenon. Understanding the context in which a pregnancy occurs requires a more nuanced examination. In-depth interviews were conducted with 60 men and women, aged 18-35, who had children or were pregnant. Using grounded theory analysis, themes emerged that revealed participants' ideal criteria desired before pregnancy. We stratified by those who met and did not meet these criteria. Almost universally, participants shared ideal criteria: to graduate, gain financial stability, establish a relationship, and then become pregnant. Many participants did not accomplish these goals. Those who had not met their criteria had experienced traumatic childhoods and suffered economic concerns. For this group, having children prompted positive changes within their control, but financial stability remained limited. Efforts should focus on improving circumstances for all individuals to fulfill their criteria before pregnancy.

Understanding Quality of Care and Satisfaction With Sexual and Reproductive Healthcare Among Young Men

OBJECTIVE

Sexual and reproductive healthcare (SRHC) guidelines recommend the delivery of quality preventive SRHC to males beginning in adolescence. A quality of care (QOC) framework was used to examine factors associated with young male's perceptions of QOC and satisfaction with care, which can influence their engagement and use of SRHC.

METHODS

Cross-sectional surveys were conducted from August 2014 to September 2016 with 385 male patients aged 15-24 years, recruited from primary care and sexually transmitted disease (STD) clinics. Surveys measured QOC received, satisfaction with care, and domains of a QOC framework. Poisson regression analyses examined associations between domains of quality and perceived QOC as well as satisfaction with care.

RESULTS

Over half of males reported QOC as excellent (59%) and were very satisfied with the services (56.7%). Excellent QOC and high satisfaction with services was associated with timely care, higher Clinician-Client Centeredness, and being a bisexual male. Excellent QOC was also associated with greater comfort in the clinic, being tested for human immunodeficiency virus/STDs, attending primary care settings, and receipt of higher number of SRHC services.

CONCLUSIONS

Using a QOC framework as part of providing SRHC to young males can be important in improving their perceptions of QOC and satisfaction with services.

Predictors of Discontinuation of Long-Acting Reversible Contraception Before 30 Months of Use by Adolescents and Young Women

PURPOSE

The purpose of the article was to describe adolescent and young women's rates of discontinuation of intrauterine devices (IUDs) and contraceptive implants, the extent to which discontinuation is predicted by baseline factors, reasons for discontinuation, and subsequent contraceptive initiation.

METHODS

We recruited English-speaking women, aged 13-24 years, from a family planning clinic serving clients <25 years old. Participants completed surveys before and after contraceptive initiation visits. We reviewed medical records and contacted participants who initiated use of an IUD or contraceptive implant and assessed contraceptive discontinuation before 30 months of use. We collected follow-up data on duration of use, reasons for discontinuation, and new method selected. We used multivariable regression models to ascertain factors associated with method discontinuation.

RESULTS

From 2011 to 2013, 775 young women completed surveys and initiated IUD or implant use. We determined 30-month discontinuation status of 633 women (81.7%). Among those with known outcome, fewer IUD than implant initiators had discontinued use (36.3% vs. 45.4%, p = .02). Mean duration of use was 733 days (95% confidence interval 702-763 days) for the IUD and 697 days (95% confidence interval 666-728 days) for the implant. Participants who stated at baseline that it was "very important" to avoid pregnancy were about half as likely to discontinue use. The most common reasons for discontinuation were pain (IUD) and bleeding (implant). Most participants initiated alternate contraception after discontinuing their original method.

CONCLUSIONS

Adolescents and young women who initiate an IUD or implant make decisions for discontinuation based on weighing high contraceptive effectiveness with other reproductive health values and preferences.

Opportunities lost: Barriers to increasing the use of effective contraception in the Philippines

Background

In the Philippines, one in four pregnancies are unintended and 610 000 unsafe abortions are performed each year. This study explored the association between missed opportunities to provide family planning counseling, quality of counseling and its impact on utilization of effective contraception in the Philippines.

Methods

One-hundred-one nationally representative health facilities were randomly selected from five levels of the health system. Sexually-active women 18–49 years old, wanting to delay or limit childbearing, attending primary care clinics between April 24 and August 8, 2017 were included. Data on contraceptive use, counseling and availability were collected using interviews and facility assessments. Effective contraceptive methods were defined as those with rates of unintended pregnancy of less than 10 per 100 women in first year of typical use.

Findings

849 women were recruited of whom 51.1% currently used effective contraceptive methods, 20.6% were former effective method users and 28.3% had never used an effective method. Of 1664 cumulative clinic visits reported by women in the previous year, 72.6% had a missed opportunity to receive family planning counseling at any visit regardless of level of facility, with 83.7% having a missed counseling opportunity on the day of the interview. Most women (55.9%) reported health concerns about modern contraception, with 2.9% receiving counseling addressing their concerns. Only 0.6% of former users and 2.1% never-users said they would consider starting a modern contraceptive in the future. Short and long acting reversible contraceptive methods were available in 93% and 68% of facilities respectively.

Conclusions

Missed opportunities to provide family planning counseling are widespread in the Philippines. Delivery of effective contraceptive methods requires that wider legal, policy, social, cultural, and structural barriers are addressed, coupled with systems approaches for improving availability and quality of counseling at all primary health care contacts.

Utilisation and preferences of family planning services among women in Ikosi-Isheri, Kosofe Local Government area, Lagos, Nigeria

BACKGROUND

Despite women's adequate knowledge and the obvious unmet need for family planning (FP), contraceptive prevalence in Nigeria is low. A greater understanding of the barriers to FP that informs service utilisation and preferences is needed to improve service delivery.

AIM

This study was aimed at assessing the use and preferences of FP services among women.

SUBJECTS AND METHODS

A community-based, descriptive, cross-sectional survey was carried out among 367 women (15-49 years of age) residing in Ikosi-Isheri, Kosofe local government area, who were selected by multistage sampling method. Data were collected using a pre-tested, semi-structured, interviewer-administered questionnaire and were analysed using SPSS software version 20. Frequency distributions and cross tabulations were generated. The Chi-square and Fisher's exact tests were used to determine associations, and the level of significance was set at P ≤ 0.05.

RESULTS

Although 64.0% were aware of FP, only 26.4% had ever used FP services. The contraceptive prevalence was 17.9%. Traditional or religious restrictions were given as the reasons for not using FP (40.9%). The preferred FP services were those offered at primary healthcare centres (45.2%) and teaching hospitals (33.9%) because of proximity (38.7%), privacy (14.5%) and health workers being female (22.6%). Age, level of education and marital status were associated with the utilisation of FP services (P < 0.001, P = 0.020 and P < 0.001, respectively).

CONCLUSION

Although awareness was high, uptake was low. Government health facilities were preferred. Primary healthcare should be strengthened, and FP services should be scaled up to make FP more accessible. Services should be closer to where people live while providing the privacy they desire.

Cluster randomized trial of a patient-centered contraceptive decision support tool, My Birth Control

BACKGROUND

Research suggests the need for improvement in the patient-centeredness and comprehensiveness of contraceptive counseling. My Birth Control is a tablet-based decision support tool designed to improve women's experience of contraceptive counseling and to help them select contraceptive methods that are consistent with their values and preferences.

OBJECTIVE

The objective of this study was to evaluate the effect of My Birth Control on contraceptive continuation, experience of contraceptive care, and decision quality.

STUDY DESIGN

Using a cluster randomized design, randomized at the provider level, patient participants interested in starting or changing contraception interacted with My Birth Control before their family planning visit (intervention) or received usual care (control). A postvisit survey assessed experience of care method satisfaction, decision quality, and contraceptive knowledge. Surveys at 4 and 7 months assessed the primary outcome of contraceptive continuation, along with method use, satisfaction, and unintended pregnancy. Mixed-effects logistic regression models with multiple imputation for missing data were used to examine the effect of treatment assignment.

RESULTS

Twenty-eight providers participated and 758 patients enrolled between December 5, 2014, and February 5, 2016. Participants were racially/ethnically diverse; less than a quarter self-identified as white. No effect was found on 7-month continuation (56.6% and 59.6% for intervention and control group respectively, odds ratio, 0.89; 95% confidence interval, 0.65-1.22). However, assignment to the intervention group increased reporting of the greatest Interpersonal Quality of Family Planning score (66.0% vs 57.4%, odds ratio, 1.45; 95% confidence interval, 1.03-2.05), the greatest scores on the informed decision and uncertainty subscales of the Decisional Conflict Scale (50.5% vs 43.2%, odds ratio, 1.34; 95% confidence interval, 1.0-1.80 and 41.6% vs 33.3%, odds ratio, 1.45; 95% confidence interval, 1.03-2.05), and greater knowledge.

CONCLUSION

My Birth Control had no effect on contraceptive continuation. The intervention did enhance the experience of contraceptive counseling and informed decision making, as well as contraceptive knowledge., The intervention's effect on patient experience is important, particularly given the personal nature of contraceptive decision making and the social and historical context of family planning care.

Comparing simulated client experiences with phone survey self-reports for measuring the quality of family planning counseling: The case of depot medroxyprogesterone acetate – subcutaneous (DMPA-SC) in Nigeria

Background: The quality of family planning services can have important implications for uptake and continued method use. The aim of this analysis is to examine aspects of quality for a new injectable contraceptive method, DMPA-SC (depot medroxyprogesterone acetate – subcutaneous, known as Sayana Press®), service provision and contraceptive services more broadly in Nigeria. Methods: We compared self-reports from follow-up phone surveys with users to simulated client interactions that were designed to measure the same concepts. Through mixed-methods, we sought to more deeply understand the biases associated with different data collection methods that ultimately lead to different conclusions regarding quality of contraceptive services, and to further assess to what extent these methods were suitable for detecting differences in quality across sub-groups using the case of married versus unmarried women. Results: We found that simulated clients reported lower levels of quality across all comparable quality indicators than phone survey respondents attending the same facilities. Both methods were able to detect differential treatment by marital status. Conclusions: A mixed-methods approach can provide differential insights into quality of family planning services, especially when aiming to understand both objective and subjective aspects of quality.

Patient-centered Contraceptive Counseling and Prescribing

Learning how to best meet a patient's contraceptive needs improves her chances of using her birth control consistently and is crucial to providing patient-centered care. The best contraceptive method for an individual patient is the one that is safe and that she is most comfortable using. Women's health care providers must be equipped to talk to each patient about her needs and options. The shared decision-making model in contraceptive counseling allows the patient and provider to work together in order to meet a patient's needs while remaining medically safe.

Client Preferences for Contraceptive Counseling: A Systematic Review

CONTEXT

Providers can help clients achieve their personal reproductive goals by providing high-quality, client-centered contraceptive counseling. Given the individualized nature of contraceptive decision making, provider attention to clients' preferences for counseling interactions can enhance client centeredness. The objective of this systematic review was to summarize the evidence on what preferences clients have for the contraceptive counseling they receive.

EVIDENCE ACQUISITION

This systematic review is part of an update to a prior review series to inform contraceptive counseling in clinical settings. Sixteen electronic bibliographic databases were searched for studies related to client preferences for contraceptive counseling published in the U.S. or similar settings from March 2011 through November 2016. Because studies on client preferences were not included in the prior review series, a limited search was conducted for earlier research published from October 1992 through February 2011.

EVIDENCE SYNTHESIS

In total, 26 articles met inclusion criteria, including 17 from the search of literature published March 2011 or later and nine from the search of literature from October 1992 through February 2011. Nineteen articles included results about client preferences for information received during counseling, 13 articles included results about preferences for the decision-making process, 13 articles included results about preferences for the relationship between providers and clients, and 11 articles included results about preferences for the context in which contraceptive counseling is delivered.

CONCLUSIONS

Evidence from the mostly small, qualitative studies included in this review describes preferences for the contraceptive counseling interaction. Provider attention to these preferences may improve the quality of family planning care; future research is needed to explore interventions designed to meet preferences.

THEME INFORMATION

This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

Quality of care and HIV service utilization among key populations in Zambia: a qualitative comparative analysis among female sex workers, men who have sex with men and people who use drugs

HIV epidemic control requires improving access and uptake of HIV services by key populations (KPs). In Zambia, the behaviors of female sex workers (FSWs), men who have sex with men (MSM), and people of who use drugs (PWUD) are criminalized, and little information exists about their HIV/STI service use. Using a quality of care (QOC) framework, we compared barriers to and opportunities for HIV/STI service access and uptake among the three KPs. We conducted in-depth interviews and focus group discussions with 314 KP members between July 2013 and September 2015 in eight districts. Poorer QOC was received at public health facilities compared to private, NGOs and traditional healers. Stigma and discrimination, confidentiality, and legal prosecution were barriers to service use and more salient among MSM than FSWs and PWUD. Invasive facility policies were barriers and more prominent among FSWs than MSM and PWUD. Service unavailability was of equally high salience among MSM and PWUD than FSWs. Comfort in the clinic and perceived treatment effectiveness were facilitators for all three KPs. The health care experiences of KPs are not monolithic; HIV/STI service improvement strategies should address the concerns and be tailored to the needs of each key population.

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.

Women's preferences for contraceptive counseling in Mexico: Results from a focus group study

BACKGROUND

Client-centered contraceptive counseling is critical to meeting demand for contraception and protecting human rights. However, despite various efforts to optimize counseling, little is known outside of the United States about what individuals themselves value in counseling. In the present study we investigate women's preferences for contraceptive counseling in Mexico to inform efforts to improve service quality.

METHODS

We conducted applied qualitative research, using six focus group discussions with 43 women in two cities in Mexico with distinct sizes and sociocultural contexts (Mexico City and Tepeji del Río, Hidalgo) to assess contraceptive counseling preferences. We used a framework approach to thematically code and analyze the transcriptions from focus groups.

RESULTS

Consistent with quality of care and human rights frameworks for family planning service delivery, participants expressed a desire for privacy, confidentiality, informed choice, and respectful treatment. They expanded on usual concepts of respectful care within family planning to include avoidance of sexual assault or harassment-in line with definitions of respectful care in maternal health. In contrast to counseling approaches with method effectiveness as the organizing principle, participants preferred counseling centered on personalized assessments of needs and preferences. Many, particularly older, less educated women, highly valued hearing provider opinions about what method they should use, based on those personalized assessments. Participants highlighted the necessity of clinical assessments or physical exams to inform provider recommendations for appropriate methods. This desire was largely due to beliefs that more exhaustive medical exams could help prevent negative contraceptive outcomes perceived to be common, in particular expulsion of intra-uterine devices (IUDs), by identifying methods compatible with a woman's body. Trust in provider, built in various ways, was seen as essential to women's contraceptive needs being met.

CONCLUSIONS

Findings shed light on under-represented perspectives of clients related to counseling preferences. They highlight specific avenues for service delivery improvement in Mexico to ensure clients experience privacy, confidentiality, informed choice, respectful treatment, and personalized counseling-including around reasons for higher IUD expulsion rates postpartum-during contraceptive visits. Findings suggest interventions to improve provider counseling should prioritize a focus on relationship-building to foster trust, and needs assessment skills to facilitate personalization of decision-making support without imposition of a provider's personal opinions. Trust is particularly important to address in family planning given historical abuses against women's autonomy that may still influence perspectives on contraceptive programs. Findings can also be used to improve quantitative client experience measures.

Provider perspectives on PrEP for adolescent girls and young women in Tanzania: The role of provider biases and quality of care

BACKGROUND

Oral pre-exposure prophylaxis (PrEP) has the potential to reduce HIV acquisition among adolescent girls and young women (AGYW) in sub-Saharan Africa. However, health care providers' (HCPs) perspectives and interactions with potential clients can substantially influence effective provision of quality health services. We examine if HCPs' knowledge, attitude, and skills, as well as their perceptions of facility readiness to provide PrEP are associated with their willingness to provide PrEP to AGYW at high risk of HIV in Tanzania.

METHODS

A self-administered questionnaire was given to 316 HCPs from 74 clinics in two districts and 24 HCPs participated in follow-up in-depth interviews (IDIs). We conducted bivariate and multivariable Poisson regression to assess factors associated with willingness to provide PrEP to AGYW. Thematic content analysis was used to analyze the IDIs, which expanded upon the quantitative results.

RESULTS

Few HCPs (3.5%) had prior PrEP knowledge, but once informed, 61.1% were willing to prescribe PrEP to AGYW. Higher negative attitudes toward adolescent sexuality and greater concerns about behavioral disinhibition due to PrEP use were associated with lower willingness to prescribe PrEP. Qualitatively, HCPs acknowledged that biases, rooted in cultural norms, often result in stigmatizing and discriminatory care toward AGYW, a potential barrier for PrEP provision. However, better training to provide HIV services was associated with greater willingness to prescribe PrEP. Conversely, HCPs feared the potential negative impact of PrEP on the provision of existing HIV services (e.g., overburdened staff), and suggested the integration of PrEP into non-HIV services and the use of paramedical professionals to facilitate PrEP provision.

CONCLUSIONS

Preparing for PrEP introduction requires more than solely training HCPs on the clinical aspects of providing PrEP. It requires a two-pronged strategy: addressing HCPs' biases regarding sexual health services to AGYW; and preparing the health system infrastructure for the introduction of PrEP.

Factors determining quality of care in family planning services in Africa: a systematic review protocol

REVIEW OBJECTIVE AND QUESTIONS

The objective of this systematic review is to identify and synthesize the best available quantitative and qualitative evidence to understand the factors determining quality of care in family planning services in Africa.The review question for the quantitative component of the review is:What factors, including facility, provider and client characteristics, are associated with quality of care in family planning services in Africa?The review question for the qualitative component of the review is:What are client and provider experiences and/or perceptions of factors that affect quality of care in family planning services in Africa?

Development and field testing of a decision support tool to facilitate shared decision making in contraceptive counseling

OBJECTIVE

We developed and formatively evaluated a tablet-based decision support tool for use by women prior to a contraceptive counseling visit to help them engage in shared decision making regarding method selection.

METHODS

Drawing upon formative work around women's preferences for contraceptive counseling and conceptual understanding of health care decision making, we iteratively developed a storyboard and then digital prototypes, based on best practices for decision support tool development. Pilot testing using both quantitative and qualitative data and cognitive testing was conducted. We obtained feedback from patient and provider advisory groups throughout the development process.

RESULTS

Ninety-six percent of women who used the tool in pilot testing reported that it helped them choose a method, and qualitative interviews indicated acceptability of the tool's content and presentation. Compared to the control group, women who used the tool demonstrated trends toward increased likelihood of complete satisfaction with their method. Participant responses to cognitive testing were used in tool refinement.

CONCLUSION

Our decision support tool appears acceptable to women in the family planning setting.

PRACTICE IMPLICATIONS

Formative evaluation of the tool supports its utility among patients making contraceptive decisions, which can be further evaluated in a randomized controlled trial.

Quality of reproductive healthcare for adolescents: A nationally representative survey of providers in Mexico

OBJECTIVE

Adolescents need sexual and reproductive health services but little is known about quality-of-care in lower- and middle-income countries where most of the world's adolescents reside. Quality-of-care has important implications as lower quality may be linked to higher unplanned pregnancy and sexually transmitted infection rates. This study sought to generate evidence about quality-of-care in public sexual and reproductive health services for adolescents.

METHODS

This cross-sectional study had a complex, probabilistic, stratified sampling design, representative at the national, regional and rural/urban level in Mexico, collecting provider questionnaires at 505 primary care units in 2012. A sexual and reproductive quality-of-healthcare index was defined and multinomial logistic regression was utilized in 2015.

RESULTS

At the national level 13.9% (95%CI: 6.9-26.0) of healthcare units provide low quality, 68.6% (95%CI: 58.4-77.3) medium quality and 17.5% (95%CI: 11.9-25.0) high quality reproductive healthcare services to adolescents. Urban or metropolitan primary care units were at least 10 times more likely to provide high quality care than those in rural areas. Units with a space specifically for counseling adolescents were at least 8 times more likely to provide high quality care. Ministry of Health clinics provided the lowest quality of service, while those from Social Security for the Underserved provided the best.

CONCLUSIONS

The study indicates higher quality sexual and reproductive healthcare services are needed. In Mexico and other middle- to low-income countries where quality-of-care has been shown to be a problem, incorporating adolescent-friendly, gender-equity and rights-based perspectives could contribute to improvement. Setting and disseminating standards for care in guidelines and providing tools such as algorithms could help healthcare personnel provide higher quality care.

A Computerized Family Planning Counseling Aid: A Pilot Study Evaluation of Smart Choices

CONTEXT

Resource constraints may make it challenging for family planning clinics to provide comprehensive contraceptive counseling; technological tools that help providers follow recommended practices without straining resources merit evaluation.

METHODS

A pilot study using a two-group, posttest-only experimental design evaluated Smart Choices, a computer-based tool designed to help providers offer more patient-centered counseling and enable patients to participate proactively in the counseling session. In two North Carolina family planning clinics, 214 women received usual counseling in March-May 2013, and 126 women used Smart Choices in May-July 2013. Exit interviews provided data for the evaluation. Multivariate Poisson and multinomial logistic regression analyses were performed to examine group differences in counseling outcomes.

RESULTS

Three of 12 hypotheses tested were supported: Compared with controls, women in the intervention group knew more contraceptive methods (adjusted mean, 11.1 vs. 10.7); discussed more topics related to sexual health during counseling (1.2 vs. 0.9 among those reporting any discussion); and rated counseling as more patient-centered, an indication of how well they felt providers understood their family planning circumstances and ideas (3.9 vs. 3.7 on a scale of 1-4). Contrary to another hypothesis, controls were more likely than women in the intervention group to choose IUDs and implants.

CONCLUSIONS

Computerized counseling aids like Smart Choices are in an early stage of development. Future research is warranted to develop tools that lead to more productive and individualized clinic visits and, ultimately, to more effective contraceptive use and reduced levels of unintended pregnancy.

Factors Determining Quality of Care in Family Planning Services in Africa: A Systematic Review of Mixed Evidence

BACKGROUND

Improving use of family planning services is key to improving maternal health in Africa, and provision of quality of care in family planning services is critical to support higher levels of contraceptive uptake. The objective of this systematic review was to synthesize the available evidence on factors determining the quality of care in family planning services in Africa.

METHODS

Quantitative and qualitative studies undertaken in Africa, published in English, in grey and commercial literature, between 1990 and 2015 were considered. Methodological quality of included studies was assessed using standardized tools. Findings from the quantitative studies were summarized using narrative and tables. Client satisfaction was used to assess the quality of care in family planning services in the quantitative component of the review. Meta-aggregation was used to synthesize the qualitative study findings.

RESULTS

From 4334 records, 11 studies (eight quantitative, three qualitative) met the review eligibility criteria. The review found that quality of care was influenced by client, provider and facility factors, and structural and process aspects of the facilities. Client's waiting time, provider competency, provision/prescription of injectable methods, maintaining privacy and confidentiality were the most commonly identified process factors. The quality of stock inventory was the most commonly identified structural factor. The quality of care was also positively associated with privately-owned facilities. The qualitative synthesis revealed additional factors including access related factors such as 'pre-requisites to be fulfilled by the clients and cost of services, provider workload, and providers' behaviour.

CONCLUSION

There is limited evidence on factors determining quality of care in family planning services in Africa that shows quality of care is influenced by multiple factors. The evidence suggests that lowering access barriers and avoiding unnecessary pre-requisites for taking contraceptive methods are important to improve the quality of care in family planning services. Strategies to improve provider behavior and competency are important. Moreover, strategies that minimize client waiting time and ensure client confidentiality should be implemented to ensure quality of care in family planning services. However, no strong evidence based conclusions and recommendations may be drawn from the evidence. Future studies are needed to identify the most important factors associated with quality of care in family planning services in a wider range of African countries.

Long-acting family planning method switching among revisit clients of public health facilities in Dire Dawa, Ethiopia

BACKGROUND

"Contraceptive switching" from one method to another is a common phenomenon. Switching from a more effective long-acting method to a less effective method exposes women for unplanned pregnancy. The aim of this study was to assess the level and factors associated with long-acting family planning method switching to other methods.

METHOD

A facility-based cross-sectional study was conducted from January to March 2013 on 634 women attending public health facilities in Dire Dawa City Administration, Ethiopia. Participants of the study were revisit clients of family planning service and were interviewed as they appear in the clinics. Data were analyzed using crude and adjusted logistic regression, and results were reported using OR and corresponding 95 % CI.

RESULTS

Long-acting family planning method switching among revisit clients was 40.4 %; switching from implant was 29.8 % and from IUCD, it was 10.6 %. The main reasons for methods switching were side effects of the methods such as bleeding, weight loss, and feeling of arm numbness. The tendency of switching was less among married women (AOR = 2.41, 95 % CI: 1.01, 5.74), women who had 2-4 and 5 and more children (AOR 3.00, 95 % CI: 1.59, 5.67) and (AOR 2.07, 95 % CI: 1.17, 3.66), respectively. It was also less among women who want to stop birth (AOR 5.11, 95 % CI: 1.15, 24.8), among those who mentioned health care providers as source of information for family planning (AOR 1.88, 95 % CI: 1.18, 3.01), and among women whose husbands were aware of their use of the methods (AOR 3.05, 95 % CI: 1.88, 4.94).

CONCLUSIONS

Method switching from long-acting contraceptives to less effective methods is high. Method switching was significant among unmarried women, who had one child, plan to postpone fertility, and whose husbands were not aware of their wive's use of the method. In the provision of family planning service, the health care providers should give adequate information about each method and risks of method switching. Appropriate family planning Information Education and Communication (IEC) and Behavioral Change Communication (BCC) strategies should be emphasized.

Correlation between Social Determinants of Health and Women's Empowerment in Reproductive Decision-Making among Iranian Women

BACKGROUND & OBJECTIVES

Women empowerment is one of millennium development goals which is effective on fertility, population's stability and wellbeing. The influence of social determinants of health (SDH) on women empowerment is documented, however the correlation between SDH and women's empowerment in fertility has not been figured out yet. This study was conducted to assess correlation between social determinants of health and women's empowerment in reproductive decisions.

MATERIAL & METHODS

This was a descriptive-correlation study on 400 women who attended health centers affiliated to Shahid Beheshti University of Medical Sciences Tehran-Iran. Four hundred women were recruited using multistage cluster sampling method. The tools for data collection were 6 questionnaires including; 1) socio-demographic characteristics 2) women's empowerment in reproductive decision-making, 3) perceived social support, 4) self-esteem, 5) marital satisfaction, 6) access to health services. Data were analyzed by SPSS-17 and using Pearson and Spearman correlation tests.

RESULTS

Results showed 82.54 ± 14.00 (Mean±SD) of total score 152 of women's empowerment in reproductive decision making. All structural and intermediate variables were correlated with women's empowerment in reproductive decisions. The highest correlations were demonstrated between education (among structural determinants; r= 0.44, P< 0.001), and Self-esteem (among intermediate determinants; r= 0.34, P< 0.001) with women's empowerment in fertility decision making.

CONCLUSION

Social determinants of health have a significant correlation with women's empowerment in reproductive decision-making.

Variation in Pregnancy Options Counseling and Referrals, And Reported Proximity to Abortion Services, Among Publicly Funded Family Planning Facilities

CONTEXT

As frontline providers, publicly funded family planning clinics represent a critical link in the health system for women seeking information about pregnancy options, yet scant information exists on their provision of relevant services. Understanding their practices is important for gauging how well these facilities serve patients' needs.

METHODS

A 2012 survey of 567 publicly funded family planning facilities in 16 states gathered information on referral-making for adoption and abortion services, and perceived proximity to abortion services. Chi-square, multivariable logistic regression and multinomial logistic regression analyses were performed to assess differences among facilities in referral-making and reported proximity to abortion services.

RESULTS

Abortion referrals were provided by a significantly smaller proportion of providers than were adoption referrals (84% vs. 97%). Health departments and community health centers were significantly less likely than comprehensive reproductive health centers to refer for abortion services and to have a list of abortion providers available (odds ratios, 0.1-0.2). Rural facilities were more likely than urban ones to report a distance of more than 100 miles to the closest first-trimester abortion provider (relative risk ratio, 11.4), second-trimester abortion provider (8.7) and medication abortion provider (8.0). Health departments were more likely than comprehensive reproductive health centers not to know the location of the closest first-trimester, second-trimester or medication abortion provider (2.5-3.5).

CONCLUSION

A better understanding of disparities in provision of pregnancy options counseling and referrals at publicly funded family planning clinics is needed to ensure that women get timely care.

The perceived role of clinicians in pregnancy prevention among young Black women

OBJECTIVE

The purpose of this study is to identify young Black women's attitudes toward clinicians and understand how they affect contraceptive behavior.

STUDY DESIGN AND MAIN OUTCOME MEASURES

We conducted semi-structured qualitative interviews with women aged 18-23 who self-identified as Black or African-American and analyzed data using techniques informed by grounded theory. Initial codes were grouped thematically, and these themes into larger concepts.

RESULTS

Participants discussed two salient concepts related to pregnancy prevention: (1) sexual responsibility and self-efficacy and (2) the perceived limited role of health care clinicians. Women portrayed themselves as in control of their contraceptive decision-making and practices. Many viewed their life plan, to finish school and gain financial stability, as crucial to their resolve to use contraception. Participants gathered information from various sources to make their own independent decision about which method, if any, was most appropriate for their needs. Most had limited expectations of clinicians and considered in-depth conversations about details of contraceptive use to be irrelevant and unnecessary.

CONCLUSION

These findings help understand factors contributing to contraceptive decision-making. The patient-clinician interaction is a necessary focus of future research to improve sexual health discussions and understand if and what aspects of this interaction can influence behavior.

Client and Provider Perspectives on Quality of Care: A Systematic Review

CONTEXT

A central premise of the literature on healthcare quality is that improving the quality of care will lead to improvements in health outcomes. A systematic review was conducted to better inform quality improvement efforts in the area of family planning. The objective of this systematic review is to update a previous review focused on the quality of family planning services, namely, the impact of quality improvement efforts and client perspectives about what constitutes quality family planning services. In addition, this review includes new literature examining provider perspectives.

EVIDENCE ACQUISITION

Multiple databases from January 1985 through January 2015 were searched within the peer-reviewed literature that described the quality of family planning services. The retrieval and inclusion criteria included full-length articles published in English, which described studies occurring in a clinic-based setting to include family planning services.

EVIDENCE SYNTHESIS

Search strategies identified 16,145 articles, 16 of which met the inclusion criteria. No new intervention studies addressing the impact of quality improvement efforts on family planning outcomes were identified. Sixteen articles provided information relevant to client or provider perspectives about what constitutes quality family planning services. Clients and providers mostly identified the need for services that were accessible, client-centered, and equitable. Themes related to effectiveness, efficiency, and safety were mentioned less frequently.

CONCLUSIONS

Family planning services that account for both patient and provider perspectives may be more effective. Further research is needed to examine the impact of improved quality on provider practices, client behavior, and health outcomes.

Contraceptive use among young women in Estonia: Association with contraceptive services

OBJECTIVES

Our study aimed to explore the association between the use of effective contraceptive methods and access to different contraceptive services, as well as to describe accessibility-related obstacles when using contraceptive services and satisfaction with those services.

METHODS

From a population-based cross-sectional study carried out in 2004 (response rate 53.8%), the data of 16- to 24-year-old women requiring contraception (N = 868) were analysed. Factors associated with the use of effective contraceptive methods and, specifically, hormonal methods, were explored using multiple logistic regression analysis.

RESULTS

Effective contraception was used by 75.1% of the respondents. The use of effective contraceptive methods was associated with school-based sexuality education (adjusted prevalence odds ratio 2.69; 95% confidence interval 1.32 - 5.50), visiting a youth-friendly clinic (YFC) (1.82; 1.03-3.23) or a private gynaecologist (2.08; 1.11-3.92). The use of hormonal methods was additionally associated with being a native Estonian speaker and visiting a family doctor. More than half of the respondents reported some obstacle in accessing contraceptive services. The highest satisfaction ratings were given to YFCs.

CONCLUSIONS

Steps to promote the use of services that are youth-friendly and associated with better uptake of effective contraceptive methods are needed among all 16- to 24-year-old women.

Contraceptive counseling: best practices to ensure quality communication and enable effective contraceptive use

Improving the quality of contraceptive counseling is one strategy to prevent unintended pregnancy. We identify aspects of relational and task-oriented communication in family planning care that can assist providers in meeting their patients' needs. Approaches to optimizing women's experiences of contraceptive counseling include working to develop a close, trusting relationship with patients and using a shared decision-making approach that focuses on eliciting and responding to patient preferences. Providing counseling about side effects and using strategies to promote contraceptive continuation and adherence can also help optimize women's use of contraception.

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.

Nurses' Patient-Centeredness and Perceptions of Care among Medicaid Patients in Hospital Obstetrical Units

Objective. This study examined to what degree patient-centeredness-measured as an underlying ability of obstetrical nurses-influenced Medicaid patients' satisfaction with care in hospital obstetrical units. Design. Multigroup structural equation modeling design, using three cross-sectional random samples (n = 300 each) from the 2003 Press Ganey National Inpatient Database. Setting. Self-administered mail surveys. Participants. 900 Medicaid recipients recently discharged from inpatient hospital obstetrical units across the United States. Methods. Multigroup structural equation modeling was used to test the goodness of fit between a hypothesized model based on the Primary Provider Theory and patients' ratings of nurses. Results. The model fitted the data well, was stable across three random samples, and was sustained when compared to a competing model. The patient-centeredness of nurses significantly influenced overall patient satisfaction and explained 66% of its variability. When nurses' patient-centeredness increased by one standard deviation, patients' satisfaction increased by 0.80 standard deviation. Conclusion. This study offers a novel approach to the measurement of the patient-centeredness of nurses and a paradigm for increasing it and its influence on Medicaid patients' satisfaction in hospital obstetrical units.

Factors determining family planning in Catalonia. Sources of inequity

Introduction

In recent decades, the foreign population in Spain has increased significantly, particularly for Catalonia, an autonomous region of Spain (2.90% in 2000 and 15.95% in 2010) and in particular Girona province (6.18% in 2000 and 21.55% in 2010). Several studies have shown a lower use of family planning methods by immigrants. This same trend is observed in Spain. The objective of this paper is to determine the existence of differences and possible sources of inequity in the use of family planning methods among health service users in Catalonia (Spain) by sex, health status, place of birth and socioeconomic conditions.

Methods

Data were taken from an ad-hoc questionnaire which was compiled following a qualitative stage of individual interviews. Said questionnaire was administered to 1094 Catalan public health service users during 2007. A complete descriptive analysis was carried out for variables related to public health service users’ sociodemographic characteristics and variables indicating knowledge and use of family planning methods, and bivariate relationships were analysed by means of chi-square contrasts. Considering the use (or non-use) of family planning methods as a dependent variable and a set of demographic, socioeconomic and health status variables as explanatory factors, the relationship was modelled using mixed models.

Results

The analysed sample is comprised of 54.3% women and 45.7% men, with 74.3% natives (or from the EU) and 25.7% economic immigrants. 54.8% use some method of family planning, the condom (46.7%) and the pill (28.0%) being the two most frequently used methods. Statistical modelling indicates that those factors which most influence the use of family planning methods are level of education (30.59% and 39.29% more likelihood) and having children over 14 (35.35% more likelihood). With regard to the origin of the user, we observe that patients from North Africa,sub. Saharan Africa and Asia are less likely to use family planning methods (36.68%, 38.59% and 70.51%, respectively).

Conclusions

The use of family planning methods is positively related to a higher level of education and having children over 14. Factors such as sex, age, income and self-perceived health do not appear to influence their use. Furthermore, being a native of this country, the European Union or Central/South America represents a greater likelihood of use than being African or Asian. Although no general differences in use were found between sexes, the difference found in the case of Asian women stands out, with a higher likelihood of use.

Quality of the contraceptive service structure: a pilot study in Finnish health centre organisations

OBJECTIVES

To evaluate the quality of the contraceptive service structure in health centre organisations (HCOs) in western Finland and to establish whether the characteristics of the HCOs are associated with the quality measured.

METHODS

Survey data were collected from all HCOs in a university hospital area in western Finland (N = 63). Quality was evaluated using a score of ten indicators. Associations between the score and the characteristics of the HCOs were studied using rank correlation analysis and a multivariate ordered logit model.

RESULTS

Among 51 HCOs yielding complete data for the evaluation, the quality score ranged from 3 to 10, the mean being 5.8. From 25 variables studied, 'a chief nursing officer or leading nurse engaged in the HCO' (p = 0.001) and 'an appointed person responsible for management of health promotion' (p = 0.006) were found to be associated with a good score in the rank correlation analysis, and they also remained significant in multivariate analysis (Odds Ratio [OR] = 11.5, 95% confidence interval [CI] 2.3-56.5 and OR = 5.9, 95% CI 1.6-21.5, respectively).

CONCLUSIONS

In the majority of the HCOs involved, the quality of service structure was rated average, but there was much variation between the HCOs. The results of the multivariate analysis emphasise the importance of good management of services.

[Characteristics of reproductive health of women in their generative age]

INTRODUCTION

Any research of reproductive health has to encompass the relevant connotations of this complex term. In order to establish relevant multidimensional characteristics, it is necessary to assess intercorrelations of the characteristics most commonly used to describe it.

OBJECTIVE

Our aim was to describe the characteristics of reproductive health and to establish their significance in describing this term.

METHODS

Within the study of health of adult inhabitants of Serbia, on the sample of 2,817 women aged 20-49 years, the data on different reproductive health characteristics were collected by way of a structured questionnaire. By way of factorial analysis (principal components method, Kaisser Varimax criterion), representative characteristics (factors) were selected out of a large number of characteristics, describing reproductive health of women in a multidimensional way, interrelationships of the factors were explained, and carriers--the most important individual characteristics--were selected for further analysis.

RESULTS

The characteristics of female reproductive health in Serbia are poor, both from the health policy standpoint and in comparison with other countries. Reproductive health describes 7 relevant factors and their carriers (characteristics which best reflect the variability of characteristics involved in a factor). These involve sexual behaviour (self-assessed HIV infection risk), contraception (use of contraceptive devices on one's own initiative), adequate protection of reproductive health (usage of gynaecological services even when healthy), abortions (pregnancy outcome), HIV control (HIV testing usage), postpartal protection (visits of field nurses after being discharged from maternity ward) and reproductive period (doctor visits after being discharged from maternity ward).

CONCLUSION

All the characteristics of reproductive health used in various studies are not equally important in the description of this complex phenomenon. Factorial analysis can explain intercorrelations of the studied characteristics and make possible the selection of those most representative.

Hormonal contraceptive method choice among young, low-income women: how important is the provider?

OBJECTIVES

Several new methods are available, but we know little about successful integration of contraceptive technologies into services. We investigated provider factors associated with the initiation of new hormonal methods among women at high risk of unintended pregnancy.

METHODS

This cohort study enrolled 1387 women aged 15-24 starting hormonal contraception (vaginal ring, transdermal patch, oral contraceptive, or injectable) at four family planning clinics in low-income communities. We measured provider factors associated with method choice, using multinomial logistic regression.

RESULTS

Ring and patch initiators were more likely than women starting oral contraceptives to report that they chose their method due to provider counseling (p<0.001). Contraceptive knowledge in general was low, but initiation of a new method, the ring, was associated with higher knowledge about all methods after seeing the provider (p<0.001). Method initiated varied with provider site (p<0.001). These associations remained significant, controlling for demographics and factors describing the provider-patient relationship, including trust in provider and continuity of care.

CONCLUSION

Women's reports of provider counseling and of their own contraceptive knowledge after the visit was significantly associated with hormonal method initiated.

PRACTICE IMPLICATIONS

More extensive counseling and patient education should be expected for successful integration of new hormonal methods into clinical practice.

The context of unintended pregnancy among married women in the USA

BACKGROUND AND METHODOLOGY

Unintended pregnancy is a concern in the USA due to its association with adverse physical, mental, social and economic outcomes. Few studies have examined this issue among married women from a social and contextual perspective. This study targeted married women to examine factors associated with unintended pregnancy using the ecological model of health promotion that focuses attention on both individual and social environmental factors. Data from the National Survey of Family Growth (NSFG) were merged with NSFG contextual files to examine the major predictive factors.

RESULTS

Multilevel logistic regression modelling revealed that married women of lower socioeconomic status, higher parity, who lived in communities with a high rate of marital dissolution had a higher probability of an unintended pregnancy. Women reported that their husbands were likely to concur with the unintended designation of the pregnancy.

DISCUSSION AND CONCLUSIONS

This study utilised a unique perspective to examine contextual factors related to unintended pregnancy among married women. The results support the need to focus on the couple as a unit for prevention efforts. Social policies to enhance access to family planning services are necessary to improve outcomes and prevent unintended pregnancies.

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.

Effective contraceptive use: an exploration of theory-based influences

The purpose of this study was to explore factors that influence oral contraceptive (OC) use among women in Iran using the Theory of Planned Behavior (TPB) and concept of self-efficacy (SE). The study sample consisted of 360 married OC users, aged 18-49 years recruited at public health centers of Mashhad, 900 km east of Tehran. SE had the strongest association with the intent to use after the clinic visit (r = 0.784) and with actual use (r = 0.452). Family planning self-efficacy combined with TPB variables accounted for 65% of the variance for intent and 27% of the variance in behavior. The results provide support for a theory-based approach to improved family planning care that specifically addresses more effective use. Development and evaluation of culturally appropriate public education and changes in clinical efforts designed to enhance the sense of SE are discussed.

Reproductive health service preferences and perceptions of quality among low-income women: racial, ethnic and language group differences

CONTEXT

Eliminating racial and ethnic disparities in health care is an important national priority. Despite substantial research documenting such disparities, this topic has received limited attention in the reproductive health field.

METHODS

Logistic regression was used to test for group differences in three service delivery preferences and five service quality perceptions among a nationally representative sample of 1,741 low-income black, Latina and white women aged 18-34; the data were collected in 1995 and represent the most recent data available for looking at these issues.

RESULTS

English-speaking Latinas and Spanish-speaking Latinas were more likely than whites to prefer a female clinician at their visits (odds ratios, 1.8 and 3.6, respectively) and to highly value clinician continuity (1.7 and 2.2). English-speaking Latinas and blacks were more likely than whites to prefer receiving reproductive health care at a site delivering general health care (1.5 and 1.6). Both groups of Latinas were less likely than whites to give the facility environment or the patient-centeredness at their most recent reproductive health visit the highest rating (0.3-0.5). Blacks were more likely than whites to report ever having been pressured by a clinician to use contraceptives (2.3).

CONCLUSIONS

Efforts to reduce racial, ethnic and language group differences in clients' perceptions of reproductive health service quality should focus on improving client-clinician communication, the service environment and contraceptive counseling. Future research should continue to assess group differences and try to determine their underlying causes.