Favorable client perceptions of provider's interpersonal behavior in contraceptive delivery, documented in clinic exit questionnaires, appear to contradict results from qualitative evaluations and are attributed to clients' courtesy bias. In this study, trained simulated clients requested services from Ministry of Health providers in three countries. Providers excelled in courteousness/respect in Peru and Rwanda; in India, providers were less courteous and respectful when the simulated clients chose the pill. Privacy and two-way communication were less prevalent in all three countries. The findings challenge the courtesy bias interpretation. Global results from qualitative studies may have expressed the views of the minority of clients who are not treated well by providers.
This article presents an evaluation framework developed to assess the first-level effects of introducing the Standard Days Method (SDM) in Peru Ministry of Health clinics. Four questions are asked: 1) To what extent do providers routinely achieve SDM service delivery standards? 2) Is the time invested in SDM delivery consistent with program norms? 3) How does SDM delivery compare with delivery of established methods? and 4) How does SDM introduction affect delivery of established methods? A study at 62 clinics demonstrated the framework's usefulness. The Standard Days Method introduction had positive overall effects on the quality of care but provider training needed adjustments.
Background and methodology Replicating a Peruvian study, this research introduced the Standard Days Method (SDM) into Rwanda Ministry of Health clinics and evaluated client counselling on the new method against that given for contraceptive pills. Providers received technical reinforcement concerning established methods in addition to SDM training. To evaluate their quality of care, simulated clients implemented a service test in visits to 20 clinics.Results As in Peru, providers exchanged significantly more relevant information with clients who chose SDM than with those who chose pills. Also, a minority of providers posed barriers to SDM access by refusing to give SDM tools to the client until she brought her partner for consultation. ConclusionsThe findings of this study confirm that SDM counselling is generally satisfactory, although SDM training needs adjustment, and that the rigour of providers' pill counselling remains below capacity. G The requirement that the partner be present during SDM counselling must be removed.G The less detailed counselling received by pill clients shows that providers perform below capacity when they deliver this contraception method.
Many of this Journal's older readers will be familiar with the Oxford-Family Planning Association (Oxford-FPA) contraceptive study and will, indeed, have made important contributions to data collection. Accordingly, I was delighted that the Journal Editor had chosen the most recent publication from the study 1 as the subject for a Journal Review. I am also grateful to Dr Mills for taking so much trouble to produce a succinct summary of a complex paper. 2 There are, however, one or two points about the review to which I would like to draw readers' attention. First, I would like to stress that the majority of the women in the study were followed up individually until mid-1994, although individual follow-up for a substantial subgroup of women ceased earlier than this. With regard to cancer registrations and death notifications, all women (save for those who emigrated) were followed up until the end of 2004 using information provided by the National Health Service Central Registries to supplement data collected during the course of individual follow-up. Second, the Journal Review does not include any confidence intervals for the rate ratios (no doubt in the interests of saving space). This is, perhaps, of concern mainly for invasive cervical cancer where the Oxford-FPA findings were considerably more unfavourable than has been described in most other studies. As the Oxford-FPA study included only 59 cases of this disease (with only six cases in the reference group who never used oral contraceptives), confidence intervals around the rate ratios were wide. Finally, while the population studied was certainly of higher social class than the general population, it was not "predominantly Social Class I". The paper only gives the proportion of women from Social Classes I and II combined and this figure was 41%. These are relatively minor points that do not detract from the substance and conclusions of the careful review prepared by Dr Mills.
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