Balancing client preferences and population-level goals: a qualitative study of the ways in which public health providers and facility administrators interpret and incentivise quality of care in contraceptive counselling in Ethiopia, Mexico and India.

Recent work in family planning has shifted from an instrumentalist perspective on quality in contraceptive counselling, which views quality as a means to encourage contraceptive uptake, to privilege quality of care as a valued end in itself. In this context of shifting narratives about quality, it is important to understand how health systems and providers navigate potential conflicts between instrumentalist definitions of quality versus a person-centred definition that considers meeting clients' contraceptive needs and preferences as an important end goal in and of itself. However, we know little about how providers and other health system stakeholders interpret the concept of quality in counselling, and how their experiences with different quality monitoring systems influence their ability to provide person-centred care. This qualitative study draws from 51 in-depth interviews with public healthcare providers and health facility administrators in Ethiopia, Mexico and India. Across all three countries, except for some cases in India, administrators were concerned with encouraging uptake of contraceptives in order to meet local and national level goals on contraceptive uptake and maternal health. In contrast, providers were more concerned with responding to client desires and needs. However, participants across all levels shared the opinion that successful counselling should end with contraceptive uptake. We conclude that the instrumentalist view of quality counselling continues to prevail across all three countries. Our findings suggest that encouraging healthcare providers and administrators to meet even relatively broad targets set by government reinforces an instrumentalist approach, as opposed to an approach that privileges person-centred care.

Reduction of the Quality of Contraceptive Counseling (QCC) scale to a short version (QCC-10) in Ethiopia, India, and Mexico.

OBJECTIVE: To reduce the Quality of Contraceptive Counseling (QCC) scale to a shortened version, coined the QCC-10, for use in measuring client-reported quality of counseling across varied settings. STUDY DESIGN: Secondary psychometric analysis of data collected for validating full versions of the QCC scale (QCC-Mexico, QCC-Ethiopia, QCC-India) and expert voting to reduce the original 26 QCC items to a 10-item set. RESULTS: Exploratory factor analysis revealed a clear one-factor solution for the QCC-10 in each country. Factor loadings were consistently >0.4 for all but two items; both were retained due to their importance to content validity. Internal consistency reliability of the QCC-10 was α=0.8 in Mexico and Ethiopia, and α=0.5 in India. QCC-10 scores were highly and positively correlated with a dichotomous overall measure of client experience and intention to initiate selected method, indicating convergent validity. CONCLUSION: The QCC-10 offers an innovative, cross-cultural approach to measuring quality in contraceptive counseling. Future efforts should examine its validity and reliability for use globally, with additional exploration of how to best measure negative aspects of care, particularly in India where such items were problematic. Thoughtful, nuanced measurement of client perspectives on their counseling experiences, available via the QCC-10, is critical to monitoring and improving quality of person-centered care and the fulfilment of human rights in contraceptive services worldwide. IMPLICATIONS: Cross-cultural, person-centered measures of quality in contraceptive counseling, such as the QCC-10, can help inform efforts to improve quality of family planning services and fulfillment of human rights. Future work will continue to explore the validity of this 10-item measure for use in various settings.

Human papillomavirus vaccine delivery strategies that achieved high coverage in low- and middle-income countries.

OBJECTIVE: To assess human papillomavirus (HPV) vaccination coverage after demonstration projects conducted in India, Peru, Uganda and Viet Nam by PATH and national governments and to explore the reasons for vaccine acceptance or refusal. METHODS: Vaccines were delivered through schools or health centres or in combination with other health interventions, and either monthly or through campaigns at fixed time points. Using a two-stage cluster sample design, the authors selected households in demonstration project areas and interviewed over 7000 parents or guardians of adolescent girls to assess coverage and acceptability. They defined full vaccination as the receipt of all three vaccine doses and used an open-ended question to explore acceptability. FINDINGS: Vaccination coverage in school-based programmes was 82.6% (95% confidence interval, CI: 79.3-85.6) in Peru, 88.9% (95% CI: 84.7-92.4) in 2009 in Uganda and 96.1% (95% CI: 93.0-97.8) in 2009 in Viet Nam. In India, a campaign approach achieved 77.2% (95% CI: 72.4-81.6) to 87.8% (95% CI: 84.3-91.3) coverage, whereas monthly delivery achieved 68.4% (95% CI: 63.4-73.4) to 83.3% (95% CI: 79.3-87.3) coverage. More than two thirds of respondents gave as reasons for accepting the HPV vaccine that: (i) it protects against cervical cancer; (ii) it prevents disease, or (iii) vaccines are good. Refusal was more often driven by programmatic considerations (e.g. school absenteeism) than by opposition to the vaccine. CONCLUSION: High coverage with HPV vaccine among young adolescent girls was achieved through various delivery strategies in the developing countries studied. Reinforcing positive motivators for vaccine acceptance is likely to facilitate uptake.