The PCFP intervention built upon on an ongoing effort by the government of Uttar Pradesh (UP), India to improve contraceptive access through deployment of ASHAs into urban areas of UP. The intervention was conducted within the context of The Challenge Initiative for Healthy Cities (TCIHC) program, which works alongside the government to provide enhanced training in family planning counselling and method options to this new cadre of urban ASHAs. The aim of TCIHC is to encourage uptake of modern family planning methods for delay of first pregnancy and/or spacing between births among urban women with unmet need aged 18 to 24.
The intervention described in this paper added to the standard family planning counselling training that ASHAs received by including a training module focused on salient PCFP domains as described by Sudhinaraset and colleagues (Sudhinaraset et al., 2018) (15). The intervention consisted of a four-hour training focused on areas of PCFP that may be most relevant to community health workers; namely respect, communication, trust, and autonomy. The training also covered the importance of person-centered care, family planning method mix and supporting clients (women) in choosing appropriate family planning methods (informed choice). The training was interactive, including case studies and role play sessions for the ASHAs to practice providing counselling to different types of clients and to think through their own experiences of poor treatment, discrimination, and their own unconscious bias. The intervention training was initially pilot tested via a training of trainers (ToT) in Uttar Pradesh and conducted with program managers, clinicians and project officers with expertise in family planning. ToT participants provided feedback on cultural acceptability and appropriateness, as well as relevance of PCFP focus areas for community health workers. The intervention training was adapted accordingly and additionally pilot-tested with a group of 21 ASHAs working in an urban area comparable to study site locations. Pre-post pilot survey results indicated that ASHAs agreed or strongly agreed that the training was helpful to their work, the training content was important for ASHAs, training in PCFP would help them to provide better care, and that they desired further training in PCFP. Further adaptations to the intervention training content were then made based on feedback received from pilot participants during the training and within qualitative responses contained in the pre-post survey. The intervention training was conducted across two different groups of 20 urban ASHAs each in January 2019. Pre-post survey responses indicated that almost all (32/40) training participants agreed that the training in PCFP would help them to provide better care and more than two-thirds agreed that they learned something new during the intervention training.
We evaluated the additional PCFP component add-on to the family planning training provided through TCIHC in 4 intervention UPHCs compared to 4 control UPHCs in Varanasi, Uttar Pradesh. Varanasi has a total population of 36.77 lakh (approximately 3.7 million) per the 2011 Indian census. Of the total population, 44.4 percent live in urban areas. About 57% of currently married women in the age group of 15–49 years were using any family method in the urban area of Varanasi district (NFHS 4, 2015-16). Intervention and control sites were matched by considering the estimated number of women with unmet family planning need, number of ASHAs, number of UPHCs, urban population of women, and age ratios.
We collected surveys with women who had been visited by an ASHA in both control and intervention areas approximately 3 months post-intervention. In order to detect a 10% difference in mean PCC score between intervention and control groups, we interviewed 542 women per arm, for a total of 1,084 women. Within each arm, we interviewed 271 women who had taken up family planning and 271 women who had not. Survey data was collected between April-June of 2019. We also conducted qualitative interviews with a subset of ASHAs in both intervention and control areas (N = 20) lasting between one to two hours. Interviews were conducted in April and May of 2019.
Surveys with women: Eligibility criteria for the survey included women in the age group of 15–49 years who had been seen by an ASHA from one of the 4 intervention or 4 control UPHCs in the last three months and adopted or switched to a new method. Women who were previously using a method and did not change the method in the last three months were excluded from the study. Women in both control and interventions areas who had seen an ASHA within the previous three months were surveyed to understand the quality of their experience with the ASHA and whether the woman had taken up a FP method of her choice following interaction with the ASHA. Women who agreed to participate in the study provided verbal consent and were interviewed at their residence. Women who did not meet eligibility criteria, refused participation following an explanation of the study’s purpose or who refused to consent to participation were excluded from the study. A standard structured questionnaire was employed by trained data collectors and each interview took approximately 30–40 minutes.
Qualitative interviews with ASHAs: A sample cohort of twenty ASHAs was purposively selected from the intervention and control arm of the study. ASHA were sampled to be roughly half in control and half in intervention groups and within each of those, some to had been working for < 3 years and some more than 3 years as ASHA. In-depth interview guides were developed to elicit the perspectives of ASHAs on their experiences providing family planning counselling to clients. Intervention participants were also asked about their perception of the integration of PCFP into their existing family planning practices. Before starting each interview, verbal informed consent was collected from participants by the lead interviewer. Participants were also informed that involvement in the interview was voluntary and that they were free to terminate participation at any point. Using an introductory script, participants were also informed that no information from the voluntary interview would be shared with their supervisors, clinic staff, or any government officials in a way that could identify them. Interviews were audio recorded and notes were taken throughout their duration. Audio recordings were transcribed in Hindi and then translated into English for analysis.
This study received IRB approval from the University of California, San Francisco (IRB # 15-25950).
Person-centered care: There were 15 individual items asked to women about their person-centered care experience with the ASHA. We adapted the PCFP scale discussed above that was validated in Uttar Pradesh for women who sought care in a facility to be more appropriate for women seeing an ASHA (15). Some items were dropped that specifically related to more technical procedures or facility environment, leaving 15 of the original 22 items. Remaining items were slightly re-worded to be reflective of visits in the home with an ASHA.
Our first step was to validate the PCFP scale previously validated in India among women who saw a provider in a facility among women who saw the ASHA. We followed the same factor analysis procedures as in the initial validation, described in detail in Sudhinaraset et al (15). The initial validation paper identified two sub-scales. We only included items from the “autonomy, respectful care, and communication” subscale because the other sub-scale was related to the health facility environment which was not relevant for community health workers visiting women in their homes. We found that all of the items in the facility-validated PCFP sub-scale loaded well onto 1 factor in this analysis (alpha = 0.939). Therefore all items included in the original PCFP scale used in this analysis.
We thus created a summary score that ranged from 0–43, with higher meaning that the woman had an overall more positive, person-centered experience. We wanted to also explore each item individually. Each item was ranked on a 4-point scale (“none of the time”, “some of the time”, “most of the time” and “all of the time”, for most indicators). To make interpretation and analysis easier, we created a binary value for each item where the lowest two response categories were grouped and the highest two grouped.
Other indicators of person-centered interactions: To better understand how our measure of PCFP is associated with other commonly used measures, we looked at two other measure of interactions between clients and providers. The first is a question that asked if the woman felt the ASHA was involved too much, too little, or the right amount in the decisions about what method to choose. This was made into a binary variable of “too much/too little” compared to the right amount. The second was a question asking the women if the ASHA had a preference about what method she choose: Extremely strong preference, strong, moderate, slight, none. A binary was created of extremely strong and strong compared to all others.
Family Planning use: The primary outcome variable was family planning uptake at 3 months post-ASHA training. This was measured by a question that women answered asking if she had adopted a family planning after meeting with an ASHA within the previous three months, or if she switched to a new method since the ASHA’s visit.
Socio-demographic control variables: We controlled for a number of socio-demographic factors which could impact women’s family planning use and person-centered experiences, based on previous studies in this setting. We controlled for age in groups (18–24, 25–29, 30–34 and over 35), education in groups (Illiterate/No school/Primary, Post-primary/vocational/Secondary, college or above, and still in school), and occupation (being a homemaker or not). We also controlled for caste groups (Scheduled caste/tribe (lowest), Other Backwards Castes, and General Caste) and religion (Muslim vs. Hindu). Finally, we controlled for if the woman stated that she desired more children, as this is important for understand family planning uptake.
Quantitative Analysis: First, we show the socio-demographic characteristic of women in the intervention and control groups, and overall, including testing for significant differences, using percentages and chi-squared tests. Next, we explored whether person-centered care scores or individual items (as binary values) differed between intervention and control participants, using means, percentages, and t-tests. We then ran multi-variable logistic regression models, controlling for the socio-demographics described above, to explore the association between being in the intervention and the full PCC score. Next, we explored the association, again using multi-variable logistic regression models, between PCC-scores and family planning uptake, controlling for the same socio-demographic variables. All analyses were run using STATA version 15 (16).
Qualitative Analysis: Initial summary memos were drafted for each interview transcript and continuously refined throughout the data analysis process. Each interview transcript then went through a multi-phase iterative coding process using ATLAS.ti version 8.4.2.(17). The coding process involved cycles of open coding, axial coding, and selective coding. A codebook was developed and continuously refined until agreed upon by three researchers (NDS, KG, CM). Any additions or changes to the codebook were documented. In addition to a codebook, a data matrix was created to visualize emerging themes and refine potential theories. Data was analysed using Grounded Theory and analysis continued until thematic saturation was deemed to be reached (18).