We developed the Quality of Contraceptive Counseling (QCC) Scale to improve measurement of client experiences with providers in the era of rights-based service delivery. We generated scale items drawing on the previously published QCC Framework and qualitative research on women's preferences for counseling in Mexico, and refined them through cognitive interviews (n = 29) in two Mexican states. The item pool was reduced from 35 to 22 items after pilot testing using exit interviews in San Luis Potosí (n = 257). Exploratory Factor Analysis revealed three underlying dimensions (Information Exchange, Interpersonal Relationship, Disrespect and Abuse); this dimensionality was reproduced in Mexico City (n = 242) using Confirmatory Factor Analysis. Item Response Theory analyses confirmed acceptable item properties in both states, and correlation analyses established convergent, predictive, and divergent validity. The QCC Scale and subscales fill a gap in measurement tools for ensuring high quality of care and fulfillment of human rights in contraceptive services, and should be evaluated and adapted in other contexts.

Background

Monitoring clients' experiences with contraceptive care is vital to inform quality improvement efforts and ensure fulfillment of individuals' human rights. The Quality of Contraceptive Counseling (QCC) Scale is a previously validated scale that comprehensively measures individuals' experiences receiving counseling in three subscales: Information Exchange, Interpersonal Relationship, and Disrespect and Abuse. We sought to better understand the correlation of client, provider, and visit factors with client-reported quality of contraceptive counseling in the public sector in two Mexican states using the QCC Scale.

Methods

This cross-sectional survey study used the QCC Scale total score and subscale scores as outcome variables. Explanatory variables included clients' age, LGBTTTIQ status, relationship status, number of children, education, and occupation; providers' gender and type of provider; and the reason for visit. Linear and logistic regression models assessed bivariate associations. Multivariable, multilevel mixed-effects models with clinic as a random effect were fit. All models used complete cases (n = 470).

Results

In the multilevel mixed-effects analyses, patients aged 35+ years reported worse Information Exchange (coefficient - 0.29, p = 0.01). Clients receiving care post-partum reported worse Information Exchange (coefficient - 0.25, p = 0.02) and worse total scores (coefficient - 0.15, p = 0.04) compared to clients seeking contraceptive information or methods. Clients who had 1+ children reported better Information Exchange (coefficient 0.21, p = 0.01) than those with no children. Though Disrespect and Abuse subscale scores were overall high (indicating high quality of care), we found a significant association between age and report of such negative experiences: clients in increasing age categories had increasingly higher adjusted odds of reporting no disrespect and abuse (aORs compared to the youngest group were 2.50 for those aged 19-24 years, p = 0.04; 4.53 for those 25-34 years, p = 0.01; and 6.11 for those 35+ years, p = 0.01.) CONCLUSIONS: Our findings align with previous results that younger clients have lower adjusted odds of reporting high-quality services in Mexico. There is a need for continued work supporting youth-friendly services in Mexico, and efforts should aim to ensure zero tolerance for disrespectful or coercive provider behaviors, such as pressuring or scolding clients. Improvements are also needed to ensure quality in counseling for post-partum clients, those aged 35+ years, and those without children.

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.

Introduction: Children with cancer experience significant pain and anxiety during needle-based procedures. Undertreated pain in children has long-lasting consequences and reduces the efficacy of subsequent analgesic efforts. A validated quality improvement (QI) intervention, known as the Childrens Comfort Promise, includes (1) topical anesthetics, (2) sucrose or breastfeeding for infants, (3) comfort positioning, and (4) distraction techniques, and has been shown to be highly effective in decreasing procedural pain and anxiety in children. However, there is limited data about the adoption, adaptation, and implementation of these interventions in low- and middle-income countries (LMICs). Methods: A QI pilot project utilizing the Model for Improvement of the Global Comfort Promise was implemented in four global pediatric cancer hospitals (Lima, Peru; Barretos, Brazil; Pietermaritzburg, South Africa; and Manila, Philippines). Between August 2021 and January 2023, the pilot sites identified a specific aim, co-designed the measurement strategy with St. Jude Childrens Research Hospital, and adopted, adapted, and implemented the project at their individual sites. Results: A total of 2,185 different procedures were recorded in the first year of implementation. Most patients were less than 10 years old (60.5%) and solid tumors (37.9%) were the most common diagnosis. Overall, healthcare professionals (98.3%) were satisfied with the procedures. Parents and patients reported that only 33.7% of patients experienced pain during the procedure. All (100%) parents and patients felt the healthcare teams adequately addressed their childs pain. Median self-reported adherence to ≥2 interventions was 98.0%. Challenges to the implementation of the QI initiative included lack of training, turnover of the medical staff, maintaining staff enthusiasm, and access to topical anesthetics. Each site had unique change ideas to implement the initiative. Conclusions: This multi-site, multi-country QI initiative was feasible and was successfully adopted, adapted, and implemented in the LMIC context to improve procedural pain in children (Global Comfort Promise). Additionally, this intervention resulted in high satisfaction of both healthcare professionals and patients/families. Further work is needed to overcome the challenges of topical anesthetic access and education of the workforce. Additional plans include modifying the Global Comfort Promise to include high-quality communication and expanding to additional sites with further refinement of the implementation strategy.