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Research Article

Do quality improvement interventions for person-centered family planning work? Evidence from Kenya

[version 1; peer review: 1 approved, 1 approved with reservations]
PUBLISHED 28 Apr 2020
Author details Author details

Abstract

Background: Quality of care for family planning, especially person-centered care, is important from a health and human-rights standpoint. Few interventions have aimed to improve person-centered family planning (PCFP) in low and middle-income countries. In this study, we tested the impact of a quality improvement (QI) intervention in Kenya on aspects of PCFP included in a validated measure of PCFP and on the overall PCFP scale.
Methods: We conducted QI cycles in three facilities providing family planning in Nairobi and Kiambu Counties, Kenya, with three facilities serving as controls. Cross-sectional baseline data was collected from 478 women receiving family planning in 2016 and end line data was collected from 640 in 2017-18.  We analysed the impact of the QI intervention on PCFP using difference-in-difference models.
Results: We found no impact of the QI intervention on either PCFP or the overall PCFP scale.
Conclusions: We take away key lessons learned from the null findings of the intervention that are important for future interventions. Lessons learned include the need to be flexible in light of external factors that prolonged the study and probably led to burnout; and simplifying measurement and procedures.

Keywords

Kenya, family planning, person-centered family planning, PCFP, quality improvement, Quality Improvement Collaborative, Breakthrough Series

Introduction

While there have been significant gains in contraceptive use in the past few decades, unmet need for family planning (FP) remains a significant challenge in Kenya, with 16.8% of women reporting an unmet need in 20171. Consequently, the Government of Kenya has been particularly interested in improving access to quality FP services, including a new urban program to integrate FP services into existing health services and working with health officials and community groups2. Researchers have hypothesized that poor quality of FP services, including provider competence, interpersonal relationships, choice of methods, information given to clients, and appropriate constellation of services3, may be a barrier to broader contraceptive use, particularly among lower socioeconomic status women4,5.

Person-centered and woman-centered models of FP have been proposed as important strategies to improve the quality of FP services3. These approaches for FP place the client at the center of care, working with broader health systems to ensure they receive dignified, respectful care, and that they are involved in all aspects of clinical decision-making6,7. This approach has been shown to improve client satisfaction6,8 and method continuation6.

A recent review of the limited person-centered family planning (PCFP) interventions that do exist found that only two involved quality improvement (QI) approaches9. Overall, interventions that targeted various forms of person-centered care (PCC) were generally successful at improving client perceptions of the quality of care (usually measured with a satisfaction question). Results were mixed for outcomes such as FP knowledge, uptake and continuation. With regard to the two QI interventions identified, the first focused solely on FP in Kenya and provided training for facilities on aspects of PCC as well as the facility environment10. This intervention found impacts at the supervisory and provider levels and in observations of client-provider interactions; however, it did not find an impact on client reports of person-centered outcomes such as satisfaction, privacy, being treated well, confidentiality, and cleanliness of the facility. The second, in Malawi, focused on many aspects of maternal and reproductive health, including FP, and mostly measured more clinically related outcomes. Generally, the QI intervention did not impact outcomes for FP, however, respondents in the intervention group were more likely post intervention to say that the provider “established a cordial relationship and identified her needs”11.

QI methodologies have been implemented across various global healthcare settings to improve both processes and health outcomes. In 1995, the Institute for Health Improvement developed a QI framework called the “Breakthrough Series” (BTS) to support healthcare systems in making improvements while simultaneously reducing costs12. A key aim of the BTS is collaborative learning, which is facilitated by bringing together multi-disciplinary QI teams to work on common challenges typically over 9–12 months. Within a BTS or Improvement Collaborative, QI teams agree on collaborative and facility aims for improvement, share their performance using common measures and then work individually during quarterly “action periods”” to secure improvements. After each action period, participants in the Collaborative meet together to discuss progress from the previous period, set aims for the upcoming action period and identify potential changes they could make to improve outcomes. Improvement Collaboratives use Plan-Study-Do-Act (PDSA) cycles to test and adapt change strategies aimed at improving the selected outcome13. The BTS has been used to successfully secure improvements in maternal and child health in low-and middle-income countries (LMIC) settings and has been demonstrated to be cost-effective in resource-constrained environments14,15. We conducted an intervention using QI cycles to improve PCFP in three facilities in Nairobi and Kiambu Counties, Kenya, and explored the impact on PCFP related outcomes, compared to three comparison facilities., To our knowledge, this is the first application of the BTS to secure PCFP improvements in LMICs.

Methods

Step 1: Baseline data collection

First, six public health facilities providing family planning and delivery care were selected in Nairobi and Kiambu Counties, Kenya. Baseline data was collected from 478 women who had recently taken up a FP method from all facilities between August and September 2016. Data was collected to understand baseline PCC performance for FP clients so that we could inform the intervention and compare to endline data. Female research assistants surveyed women in a private location within the facility grounds for both baseline and endline for all six facilities, after the women completed a written informed consent. Interviews were conducted in the respondent’s preferred language (English or Kiswahili or a mix of both) and took roughly 45 mins-1 hour. The survey (Extended data16) was read to respondents and data were entered into a tablet. Data was collected on women’s experiences of receiving their family planning method, method choice and uptake, as well as socio-demographics. The main outcome of interest is a validated scale for PCFP constructed by Sudhinaraset and colleagues7. The validated PCFP scale for Kenya included 20 items, which fell into 2 sub-domains, “autonomy, respectful care, and communication” and “health facility environment.” The paper describing the validation process also describes the data collection approach in more detail7.

Step 2: QI Intervention development and implementation

Three of these facilities were selected to participate in a QI intervention to improve PCC for FP clients and childbirth patients, while the remaining three were assigned to a control arm. An Improvement Collaborative was then designed utilizing the BTS model12 and QI teams were formed at each intervention facility. Initially, health facility managers were requested to nominate members from a range of staff disciplines suggested by the external QI expert (e.g. doctors, midwives, data clerks, support staff). Over time, QI team members recruited additional colleagues to cover gaps when pivotal staff were moved or greater representation was needed.

Over the course of the 9-month Collaborative, the QI teams worked together to improve four specific PCC topics in FP. The QI intervention was implemented over an extended time period due to delays related to two national strikes of healthcare providers that occurred during the study period. The intervention began in June of 2017 and completed in October of 2018. Intervention facilities developed change ideas to improve performance on the following person-centered family planning care topics: 1) Health care providers introduce themselves to the client; 2) Healthcare providers call the client by her name; 3) Doctors and nurses asked the client how she was feeling; and 4) The client felt she could ask any questions that she had. Topics were chosen based on data from the baseline survey about gaps. Intervention facilities focused on developing change ideas for a specific set of topics for three months, and focused on new topics in the subsequent quarter.

Step 3: End line data collection

An endline evaluation (Extended data16) of 640 women was conducted across all six study sites between October 2018 and April 2019 to assess intervention impact. The same recruitment and data collection approach was used as at baseline (described above).

Data analysis

We ran a series of difference-in-differences models on various outcomes related to PCC. Per standard practice, the difference-in-differences estimators included a variable for time (baseline/endline), a variable for intervention (intervention/control) and a multiplier of these two (time*intervention). The primary outcomes explored included looking at PCFP overall and the specific topics focused on in the QI intervention7. A higher score on the PCFP scale indicated a more positive experience at the time of receiving family planning counselling and a method.

We first compared the population in the control and intervention facilities using t-tests to see if any significant demographic differences emerged. We then explored the change in the mean PCFP score and sub-scales between baseline and endline, and between control and intervention facilities, using t-tests. Finally, we conducted a series of difference-in-differences models that looked at the impact of the intervention on the following: the full PCFP score, two subscales (“autonomy, respectful care and communication” and “health facility environment”) and the four specific topic areas that facilities focused on in the Improvement Collaborative. Not all facilities worked on all four “improvement” topics, therefore analysis of performance differences between baseline and endline for these four topics excluded non-participatory facilities. All data analysis was conducted in Stata version 1517.

Ethical approval

This study (intervention and data collection) was approved by the Institutional Review Board at The University of California, San Francisco [# 15-18008] and the Kenya Medical Research Institute’s Scientific and Ethics Review Unit {# Non-KEMRI 526}. All subjects have provided written consent to participate in study activities under these approvals.

Results

Table 1 shows the demographics of respondents, broken down by those in intervention and control facilities. All in all there were 227 women in the control and 292 women in the intervention facilities at baseline, and 294 women in the control and 349 women in the intervention facilities at end line (no significance difference in sample size). Intervention and control facilities were significantly different in terms of age, with control facilities having more younger women. There were no significant differences between intervention and control participants in terms of marital status, work, parity, or education. Women in the intervention facilities were more likely to be of the dominant tribe (Kikuyu) than in control facilities. Most women (77.6%) adopted a long-term FP method, with no differences between intervention and controls. About a third (33.2%) of all women said they were very satisfied with their care, and most said that the provider had no preference, a slight preference, or a moderate preference about what method they adopted, again with no difference between control and intervention facilities (80.1%).

Table 1. Comparison of demographics by control and intervention facilities.

ControlInterventionTotal
No.%No.%No.%
52144.9563855.051159100
Age category
Under 20193.6101.6292.5
20–2418234.920331.838533.2
25–2916331.323036.139333.9
30 and over15730.119530.635230.4
Pearson chi2(3) = 9.0756 Pr = 0.028
Marital status
Single, cohabiting, partnered, divorced, widowed7614.68614.416214.5
Married44585.451185.695685.5
Pearson chi2(3) = 6.9537 Pr = 0.073
Number of births
121742.224642.146342.2
216732.519232.935932.7
39017.510417.819417.7
4+407.8427.2827.5
Pearson chi2(3) = 0.1544 Pr = 0.985
Working
No24647.227345.751946.4
Yes27552.832454.359953.6
Pearson chi2(1) = 0.2477 Pr = 0.619
Education
No school/Primary1773421936.739635.4
Post-primary/vocational/Secondary21541.323539.445040.3
College or above12924.81432427224.3
Pearson chi2(2) = 0.9018 Pr = 0.637
Religion
Non- majority22643.424641.247242.2
Majority Religion29556.635158.864657.8
Pearson chi2(1) = 0.5381 Pr = 0.463
Tribe
Other tribe36069.126344.162355.7
Kikuyu16130.933455.949544.3
Pearson chi2(1) = 70.7258 Pr = 0.000
Type of family planning adopted
Short term (condom, pill)10620.514424.125022.4
Long term (IUD, implant, injectable)41179.545375.986477.6
Pearson chi2(1) = 2.0833 Pr = 0.149
Satisfied with care
Satisfied, dissatisfied, very dissatisfied35768.539065.374766.8
Very satisfied16431.520734.737133.2
Pearson chi2(1) = 1.2812 Pr = 0.258
Provider preference for which method adopted
None, slight, moderate preference42080.647579.689580.1
Strong, very strong preference10119.412220.422319.9
Pearson chi2(1) = 0.1920 Pr = 0.661

There was a significant improvement in PCFP scores in control facilities between baseline and endline, increasing from a mean of 41.70 to 43.20 (p=0.0245) (Table 2). There was no change in PCFP scores in intervention facilities over time.

Table 2. Mean person-centered care scores over time by intervention and control facilities.

BaselineEndlineT-test p-value
Control Facilities41.7043.200.0245
Intervention42.9542.970.9772

Difference-in-difference models showed that there was no impact of the intervention on the total PCFP scores or the two sub-scales of the PCFP scale (Table 3). When looking at the specific item-focuses of the QI intervention (for example, facilities that specifically worked on the PCFP topic “provider asking if the woman had any questions” did not see a change in reports of that item), we found that there was a significant negative impact of the intervention on the “providers calling respondents by their name” item for the combined effects of the intervention and time, even though this indicator significantly improved both over time and in intervention compared to control facilities. The sub-domain for Health Facility Environment and the item for “provider introducing themselves” significantly increased between the two survey rounds as well.

Table 3. Difference-in-difference (DID) models of the impact of the person centered care (PCC) intervention on PCC measures.

Survey roundInterventionDID
Full PCC scale0.953 (-0.381 - 2.288)2.551* (-0.477 - 5.579)-1.385 (-3.214 - 0.444)
Autonomy, respectful care,
communication
0.393 (-0.719 - 1.506)1.799 (-0.723 - 4.322)-0.924 (-2.448 - 0.600)
Health facility and environment0.456** (0.0960 - 0.816)0.503 (-0.321 - 1.328)-0.301 (-0.797 - 0.195)
Provider introduced themself (all
facilities)
0.149** (0.0248 - 0.274)-0.0174 (-0.298 - 0.263)0.150* (-0.0202 - 0.320)
Provider called the respondent
by name (all facilities)
0.567*** (0.386 - 0.748)0.448** (0.0275 - 0.868)-0.292** (-0.543 - -0.0406)
Provider asked respondent how
she was feeling (2 facilities)
0.0772 (-0.156 - 0.311)-0.0670 (-0.672 - 0.538)0.0638 (-0.296 - 0.424)
Provider asked respondent if she
had questions (1 facility)
0.0315 (-0.181 - 0.244)0.398 (-0.301 - 1.097)-0.211 (-0.623 - 0.202)

*All data presented controlling for age, marital status, education, working status, tribe, number of children and family planning method adopted

*** p<0.01, ** p<0.05, * p<0.1

Discussion

This evaluation found no impact of the intervention on women’s reports of the PCFP that they experienced. This held true for the full scale, sub-scales, and also individual items that each facility focused on in their QI work. Given the substantial body of evidence pointing toward Improvement Collaboratives as an effective intervention in low- and middle-income healthcare settings, the most likely interpretation of these results is that observed challenges hindered the QI intervention. Feedback we received from study facilities corroborates this interpretation.

First, the QI process itself may have been too cumbersome to be effective. QI teams set out to improve more topics for this project than is typical in an Improvement Collaborative. Alongside the four topics for FP, another 13 were selected for maternity care. This was necessary to try and detect an impact in the overall evaluations (the PCFP and person-centered maternity care scales). However, it dramatically increased the amount of time required to organize and analyse data in weekly QI review meetings. In addition, QI teams faced an extra burden of gathering their own performance data. QI work characteristically utilizes data that is already recorded in registers or collated for performance management purposes. Person-centered care performance is rarely monitored routinely in healthcare facilities, thus QI teams were asked to conduct their own exit interviews to assess on-going progress. This required a disproportionate amount of team effort to maintain suggested sample sizes to understand changes in QI team performance.

Delays due to two national strikes by doctors and nurses extended the overall project timeline from 9 to 21 months. This exacerbated the impact of staff turnover on QI team cohesion and continuity. The overall duration may have contributed to a decline in attendance at QI team meetings in the final three-months of the program and a sense of “improvement fatigue” reported by the expert QI facilitators.

Second, system constraints within the healthcare facilities may also have hindered the QI intervention. External evaluators noted stock-outs of FP methods reported by intervention and control facilities alike during the endline data collection period. This experience is likely to have influenced overall levels of satisfaction with the FP services, as some clients may have been asked to choose an alternative FP method or return when new supplies were available. This failure is likely to have influenced overall perceptions of PCFP in both intervention and control facilities equally, however combined with challenges noted above could have had additional impact in intervention facilities.

Disentangling potential contributors can help future interventions aimed to improve quality of FP services have better success, especially for person-centered measures or that use QI approaches. Future work to improve PCC in FP should ensure a streamlined QI process with a low burden on data collection and number of topics to improve.

Limitations

This study had a robust design with both control and intervention facilities being measured both pre and post-intervention. Despite this, there were also limitations. All respondents had selected a FP method; therefore, we were not able to measure the impact of the QI intervention on FP uptake. Additionally, our focus was only in Nairobi and Kiambu counties, which are urban and peri-urban, and thus these findings are not generalizable to other parts of Kenya or other settings.

Ethics approval and consent to participate

This study was approved by the Institutional Review Board at The University of California, San Francisco [# 15-18008] and the Kenya Medical Research Institute’s Scientific and Ethics Review Unit {# Non-KEMRI 526}. All subjects have provided written consent to participate in study activities under these approvals.

Data availability

Underlying data

Dryad: Evaluation of person centered quality improvement intervention for family planning in Kenya, https://doi.org/10.7272/Q6SX6BD916.

This project contains the following underlying data:

  • - Baseline data

  • - Endline data

Extended data

Dryad: Evaluation of person centered quality improvement intervention for family planning in Kenya, https://doi.org/10.7272/Q6SX6BD916.

This project contains the following extended data:

  • - Baseline survey

  • - Endline survey

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).

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Diamond-Smith N, Giessler K, Munson M and Green C. Do quality improvement interventions for person-centered family planning work? Evidence from Kenya [version 1; peer review: 1 approved, 1 approved with reservations]. Gates Open Res 2020, 4:44 (https://doi.org/10.12688/gatesopenres.13120.1)
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Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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