We evaluated the additional PCFP component add-on to the family planning training provided through TCIHC in four intervention UPHCs compared to four control UPHCs in Varanasi, Uttar Pradesh. Intervention and control sites were matched by considering the estimated number of women with unmet family planning need, number of ASHAs, socio-demographics of the population in each UPHC”, urban population of women, and age ratios.
We conducted 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. Systematic random sampling was used to draw sample respondents from a register kept by ASHAs for their specific supervision geographies of users and non-users of family planning. Names and status of method use were then cross-checked with UPHC health records that indicated which women were or were not using family planning methods or had discontinued or switched their family planning method. Survey data were collected between April-June of 2019. We also conducted qualitative interviews with a subset of ASHAs in both intervention and control areas (N=20) in April and May of 2019. Only the results of interviews with intervention ASHAs are described in this paper.
Surveys with women: 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 family planning method of her choice following interacting with the ASHA. 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 four intervention or four control UPHCs in the last three months. Women were identified through the ASHA registers. Since we were concerned that family planning uptake would be low, we designed our study to ensure that half of respondents would be family planning users or adopters. Of the total sample (N=1,084), 369 women had adopted a new method, 172 had switched methods, and the remaining 542 women had not adopted a method since meeting with the ASHA at a minimum of three months prior to study participation.
To recruit potential survey participants, a female enumerator trained in quantitative data collection read an introductory script outlining the length of the survey and confidentiality of responses to women who were contacted in their homes. To protect the privacy of potential respondents, the script did not indicate specifically that the survey was focused on experiences with family planning services, rather, that the survey was focused on general healthcare services received via the ASHA. If a woman agreed to participate and/or was interested in learning more about the survey, a consent form was read to and/or read by the participant which outlined voluntariness of participation, efforts that would be undertaken to protect privacy of responses and data from anyone outside of the research team inclusive of ASHAs, healthcare providers or health facilities, clarification that the research team was not affiliated with any health facility, and that participants were free to withdraw at any point. The verbal consent form explicitly stated that the questions in the survey were focused on family planning. Women who agreed to participate in the study provided verbal consent and were asked if they would prefer to conduct the survey within their own homes or at an outside location such as a community center. The enumerator then confirmed whether the participant wanted to conduct the survey at the time of consent or schedule participation at a more convenient time. The survey was a standardized structured questionnaire that took approximately 30-40 minutes to conduct. The majority of women chose to be interviewed in their homes; very few opted to be interviewed at a local community center. To ensure additional privacy for women that were interviewed in their homes, the female enumerator requested that the woman find a secluded place to participate in the interview. Additionally, the enumerator requested that additional people within the home, including husbands and mothers-in-law, allow the woman to participate in the survey in a private place within the home. 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.
Qualitative interviews with ASHAs: A sample of twenty ASHAs was purposively selected from the intervention and control arm of the study for interviews lasting one to two hours. ASHA were sampled to be roughly half in control and half in intervention groups and within each of those, we purposively sample by length of time working as an ASHA (working for <3 years and more than 3 years). In-depth interview guides were developed to elicit the perspectives of ASHAs on their experiences providing family planning counseling 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. For the purposes of this paper we only discuss findings from the intervention ASHAs.
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 (17). 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. The original PCFP scale included the following items: the provider introducing themselves, being treated with respect, trusting the provider, being given the “best care”, given information, being involved in decisions, having things explained to them, understanding what was happening, being involved in the family planning method choice, being allowed to ask questions, being allowed to have someone stay with them in their visit, and feeling that their fears were supported (Table 2) (17). We followed the same factor analysis procedures as in the initial validation, described in detail in Sudhinaraset et al (17). The initial validation paper identified two sub-scales. We only included items from the “autonomy, respectful care, and communication” sub-scale 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 PCFP sub-scale loaded well onto 1 factor in this analysis (alpha=0.939). 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 scores 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. We determined that anything other than “the right amount” as being indicative of poorer quality care as it did not meet the needs of the woman herself. The second indicator was a question asking the women if she felt that 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, with the interpretation that strong preferences were an indicator of pressure.
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 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, 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 (18).
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.(19). 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 were analysed using Grounded Theory and analysis continued until thematic saturation was deemed to be reached (20).