Setting and Data Source
The data for this study were collected by the Measurement, Learning & Evaluation (MLE) project for the impact evaluation of the Nigerian Urban Reproductive Health Initiative (NURHI), a project funded by the Bill & Melinda Gates Foundation that aimed to increase modern family planning use among the urban poor. This study utilizes health facility (N = 400, 49% hospitals, 51% primary healthcare centers) and healthcare provider (N = 1,479) baseline survey data that were collected in Abuja (Nigeria’s capitol), Benin City, Ibadan, Ilorin, Kaduna and Zaria (29). NURHI selected these cities because they include both northern and southern regions of the country and each has a population of approximately, or more than, one million. The northern and southern regions of Nigeria differ in their cultural, economic, and religious characteristics; the north is poorer and predominantly Muslim while the south is more affluent and predominantly Christian.
Study Sample
Two categories of healthcare facilities are included in the sample: high-volume facilities (HVF) and preferred- provider facilities (PPF). HVF and PPF can be either public or private, and they can be either primary or secondary facilities. The sample includes all public facilities in the study cities. HVF, generally the top service delivery sites by client load, offered both antenatal care and immunization services; these facilities served more than 1,000 antenatal clients per year. The NURHI program provided an intervention to all HVF, and all of these facilities are included in the sample (29). PPF were identified from a baseline household survey conducted by MLE that contained a representative sample of 16,144 women aged 15–49. Women were asked the name of each facility where they went for family planning, maternal health, and child health services. Using this information, MLE created a list of facilities that women reported by study cluster (primary sampling unit). The most commonly mentioned facility in each primary sampling unit was categorized as a PPF. If the PPF was already included in the sample as a public facility or an HVF, then the second most-commonly mentioned facility was included. If the second most-commonly stated facility was already in the sample, no additional facility was included. Including the PPFs along with the public facilities and HVFs ensures that the sample includes facilities that women in these urban areas actually visit.
Survey Instruments
This study utilizes instruments developed for the NURHI impact evaluation, which draws upon validated tools selected from the Quick Investigation of Quality (30). Facility and provider surveys were conducted in each facility by trained interviewers hired by Data Research and Mapping Corporation; the MLE project provided technical assistance for training of interviewers. The surveys collected information on the readiness of facilities and providers to offer integrated services, normal family planning service provision practices, gaps in commodities, equipment, training and resources, the extent of family planning integration into maternal, newborn and child health services, and other health facility characteristics. One facility audit was conducted per facility by asking questions of a manager or another administrator. In larger facilities, four providers were selected through simple random sampling to complete the provider survey; in facilities with four or fewer providers, all were approached for interview. Providers eligible for inclusion were medically qualified to provide clinical services and assigned to provide direct family planning and/or maternal, newborn and child health services to clients at that facility.
Statistical Method
This study employs Principal Components Analysis (PCA) to create two family planning and child immunization services integration indexes: a Provider Integration Index and a Facility Integration Index. All analyses were conducted using Stata version 13.1 (Stata Corp, LP, College Station, Texas).
Constructing and Interpreting the Indexes
Selection of Variables for Inclusion in the PCA
Drawing on Mayhew et al (2016), we posit that numerous characteristics and processes interact within a health facility to result in varying degrees of integrated service delivery (26). While the Nigerian Ministry of Health does not provide a specific definition of integrated family planning and immunization services, their 2008 National Guidelines for the Integration of Reproductive Health and HIV Programmes offers this explanation:
Integration in the health sector has been defined by offering two or more services at the same facility during the same operating hour, with the provider of one service actively encouraging clients to consider using the other services during the same visit, in order to make those services more convenient and efficient. Integrated services should be offered at the same point but where that is not possible, strong referral systems are required to ensure that clients receive high quality service (31).
NURHI’s Strategy for Integrating Family Planning into Maternal, Newborn, Child Health and HIV/AIDS Services references this guidance (32). This study also refers to this guidance to inform the attributes measured in the indexes. Additionally, we reviewed the integration literature to identify facility-level attributes that support service integration. Several critical attributes emerged, including a) facility norms that support concurrent service provision (e.g., operational management standards and procedures that support the availability of both child immunization and family planning services at the same consultation or on the same day), and b) provider capacity to offer multiple services (e.g., provider(s) has the skills and willingness to offer family planning information or services during a child immunization visit) (22, 26, 33–36).
Because this study was conceptualized after data collection, we leveraged the available data and selected eight indicators for inclusion in the indexes (Table 1). Table 2 describes these and other facility characteristics. A few of these indicators warrant additional explanation. Improving outcomes through integration relies upon both high coverage and quality of integrated services. A substantial body of research links higher quality family planning services with increased contraceptive adoption, prevalence, and continuation; poor family planning service quality can hinder use (37). Therefore, the level of quality provided and the absence of barriers that limit coverage and quality are essential indicators of effective integration (35, 38). We analyzed quality of integrated family planning services by measuring the range and breadth of family planning topics that providers discuss with a client during child health service visits. Because the extent of integration can be influenced by provider bias (39, 40), we include social norm-based service barriers by measuring the extent to which providers at a facility require spousal consent prior to provision of a family planning method during an integrated visit. While numerous such barriers exist and could have been employed in the indexes this is the only variable in our dataset that captures such barriers to family planning specifically during immunization visits.
Table 1
Description of PCA Input Variables
Input Variable Description | Type | Survey Source |
What proportion of providers at facility offer both CI and FP services?* | Continuous between 0 and 1 | Provider |
What proportion of providers at facility routinely offers FP information during CI or CGM visits*? | Continuous between 0 and 1 | Provider |
What is the average count of FP items that providers at facility tell client during CHS visits?** | Ordinal between 0 and 7 FP items include: 1) Identify reproductive goals 2) Provide information about different FP methods 3) Discuss the client's FP preferences 4) Help women select a suitable method 5) Educate women to use the selected method 6) Explain side effects 7) Explain specific medical reasons to return 8) Request for partner's consent prior to receipt of FP method | Provider |
What proportion of providers at facility do not request partner consent prior to woman’s receipt of FP services during CHS visit?* | Continuous between 0 and 1 | Provider |
Does the facility provide both child immunization and family planning services? | Binary (0 = no, 1 = yes) | Facility |
What is the normal practice at this facility if client wants FP information during CHS visit?*** | Ordinal between 0 and 7. Responses include: 0) Facility does not provide child health services 1) Facility does provide child health services but does not provide family planning services 2) Client is given no information or referral 3) Client is given referral to another facility 4) No appointment made, client told to return on a different day 5) Appointment made for different day 6) Client sometimes receives information on same day 7) Client always receives information on same day | Facility |
What is the normal practice at this facility if client wants hormonal method of FP during CHS visit?*** | Ordinal between 0 and 7. Responses include: 0) Facility does not provide child health services 1) Facility does provide child health services but does not provide family planning services 2) Client is given no information or referral 3) Client is given referral to another facility 4) No appointment made, client told to return on a different day 5) Appointment made for different day 6) Client sometimes receives method on same day 7) Client always receives method on same day | Facility |
What is the score of operational days when both CI and FP services are offered? | Continuous between 0 and 1. Defined as: (Proportion of operational days that child immunization services are provided) multiplied by (Proportion of operational days that family planning services are provided) | Facility |
Notes: CI: Child Immunization FP: Family Planning CGM: Child Growth Monitoring CHS: Child Health Service CHS visits include either CI or CGM visits, but not sick child visits. In variables referring to CHS visits, it was not possible to differentiate data pertaining only to CI from data pertaining only to CGM. CI visits comprise the vast majority of all CHS visits. Of the 5,440 women who participated in the concurrent health facility client exit interview, only 1.65% report that CGM was the primary purpose of their visit. * Proportion of providers was obtained from the provider survey by taking an average of provider responses to dichotomous survey questions (0 = no, 1 = yes). For example, if two providers responded that they did not routinely offer FP information during a CI or CGM visit and two responded that they did then the facility would score a 0.5 on this item. ** Facility score calculated by adding one point for affirmative responses to items 1–7. ***Facility scores reflect the response, ranked from 0 (low) to 7 (high). |
Table 2
Characteristic | Percent or Mean Value (SD) N = 400 |
Ownership | |
Publicly Owned | 41% |
Privately Owned | 59% |
Level | |
Primary | 51% |
Secondary | 49% |
Location | |
Abuja | 12% |
Benin | 18% |
Ibadan | 15% |
Ilorin | 18% |
Kaduna | 23% |
Zaria | 14% |
Proportion of facilities that offer CI and/or CGM | 0.85 (0.36) |
Facility provides CI and FP services | 0.77 (0.42) |
Normal practice if FP info wanted during CH visit | 5.82 (2.23) |
Normal practice if hormonal FP wanted during CH visit | 4.63 (1.97) |
Score of days where both CI and FP are offered | 0.29 (0.35) |
Proportion providers at facility who offer CI and at least 1 modern FP method | 0.56 (0.40) |
Proportion providers at facility who routinely offer FP info during CI/CGM | 0.58 (0.39) |
Average FP items that a provider at a facility tells client during CHS | 1.67 (1.52) |
Proportion providers at facility that do not request partner consent for FP during CHS | 0.50 (0.37) |
Notes: See Table 1 for complete variable definitions. CI: Child Immunization FP: Family Planning CGM: Child Growth Monitoring CHS: Child Health Service |
Several variables refer to child immunization, child growth monitoring, or child health service visits. Child health services visits include either immunization or growth monitoring visits, but not sick child visits. In variables referring to child health services, it was not possible to differentiate data pertaining only to child immunizations from data pertaining only to child growth monitoring. However, child immunization visits comprise the vast majority of all child health services visits. Of the 5,440 women who participated in the concurrent health facility client exit interview, only 90 (1.65%) report that child growth monitoring was the primary purpose of their visit. Facility-level variables are based on a summary of provider responses. Means were imputed for missing data.
PCA Application
PCA was applied following the selection and transformation of variables. Input variables were standardized to a mean of zero and a standard deviation of one prior to the analysis to prevent variables with greater variance from dominating each component. The Kaiser-Meyer-Olkin (KMO) test of sampling adequacy was used to ascertain the suitability of the data for use in a PCA. Our KMO test yielded a score of 0.8, indicating sampling adequacy for each variable and the complete model. Based on evaluation of the eigenvalues (Table 3) and the scree plot (Fig. 1) we retained two components. The factor loading scores (see factor loadings column in Table 4) were examined to determine which dimensions of integration are represented by the components. The scores confirmed the anticipated dimensions: provider integration and facility integration.
Table 3
Main PCA Results from Analysis of Health Facility Data from Six Cities in Nigeria
Component | Eigenvalue | Proportion of Explained Variance | Proportion of Cumulative Explained Variance |
Comp1 | 4.456 | 0.557 | 0.557 |
Comp2 | 1.532 | 0.191 | 0.748 |
Comp3 | 0.795 | 0.099 | 0.848 |
Comp4 | 0.450 | 0.056 | 0.904 |
Comp5 | 0.315 | 0.039 | 0.943 |
Comp6 | 0.256 | 0.032 | 0.975 |
Comp7 | 0.107 | 0.013 | 0.989 |
Comp8 | 0.089 | 0.011 | 0.999 |
Table 4
Provider and Facility Integration Index Scores and Variable Means by Group
| Factor Loading | Sum | Weight | Overall Mean (SD) | Integration Index Score Classification Group Means | p-values |
Provider Integration Variable Description | | | | | Low Score | Medium Score | High Score | Low-Med. | Med. -High |
Proportion providers at facility who offer CI and at least 1 modern FP method | 0.39 | 1.87 | 0.21 | 0.56 (0.4) | 0.05 | 0.47 | 0.90 | 0.00 | 0.00 |
Proportion of providers at facility who routinely offer FP info during CI/CGM | 0.41 | 1.87 | 0.22 | 0.58 (0.39) | 0.04 | 0.49 | 0.93 | 0.00 | 0.00 |
Average FP items that a provider at a facility tells client during CHS | 0.33 | 1.87 | 0.18 | 1.67 (1.52) | 0.14 | 1.76 | 3.38 | 0.00 | 0.00 |
Proportion of providers at facility that do not request consent during CHS | 0.37 | 1.87 | 0.20 | 0.5 (0.37) | 0.04 | 0.41 | 0.81 | 0.00 | 0.00 |
Facility provides CI and FP services | 0.38 | 1.87 | 0.20 | 0.77 (0.42) | 0.23 | 0.88 | 0.97 | 0.00 | 0.00 |
Provider Integration Index Score | | | | 5.42 (3.10) | 0.75 (23% of facilities) | 4.99 (32% of facilities) | 8.23 (45% of facilities) | 0.00 | 0.00 |
Physical Integration Variable Description | | | | | | | | | |
Normal practice if FP info wanted during CH visit | 0.38 | 1.21 | 0.32 | 5.82 (2.23) | 0.09 | 0.91 | 0.98 | 0.00 | 0.00 |
Normal practice if hormonal FP wanted during CH visit | 0.41 | 1.21 | 0.34 | 4.63 (1.97) | 0.05 | 0.80 | 0.96 | 0.00 | 0.00 |
Score of days where both CI and FP are offered | 0.42 | 1.21 | 0.34 | 0.29 (0.35) | 0.01 | 0.11 | 0.49 | 0.00 | 0.00 |
Physical Integration Index Score | | | | 6.22 (2.72) | 0.50 (14% of facilities) | 6.00 (38% of facilities) | 8.10 (48% of facilities) | 0.00 | 0.00 |
Creating the Indexes
We constructed the Provider Integration Index and Facility Integration Index using weights calculated for each of the variables by dividing its factor loading by the sum of the factor loadings of all variables in that component (see weights column in Table 4). Next, we multiplied the variables included in each component by their associated weights and summed the values. Finally, we calculated the Provider Integration Index score and the Facility Integration Index score for each facility by multiplying these values by ten. The indexes thus range in value from zero to ten, with a higher score indicating a higher level of integration. A sensitivity analysis was conducted to identify the effects of excluding from the sample those facilities that do not offer child immunization (n = 61); there were no statistically significant differences between the indexes that include all facilities versus those with the restricted set of facilities. We retained these facilities in the sample because one goal of the paper is to assess integration across the range of facilities and circumstances represented by our sample. Excluding these facilities would prevent us from knowing the full extent of integration across our sample. Additionally, one key benefit of developing these indexes is the ability to apply them to understand the effects of integration on health and service delivery outcomes. Having a score for facilities that do not offer child immunization allows future research to better identify correlations between level of integration (even very low level) and other outcomes.
As a robustness check, we also created the indexes using Exploratory Factor Analysis. The indexes created using EFA correlate strongly with the indexes created using PCA (Spearman rank correlation 0.99 for the Provider Indexes and 0.89 for the Facility Indexes), indicating that the results are robust to the use of either method.