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Abstract
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Before
Beyond Bias will evaluate the impact of an intervention designed to reduce family planning provider bias towards young, unmarried, and nulliparous women in Tanzania, Burkina Faso, and Pakistan. The intervention has three components: 1) a summit that includes impactful stories told to and by family planning providers that highlight the consequences of provider bias, 2) a forum for continued communication between providers, and 3) a rewards program where clinics in which providers exhibit less biased client interactions or who have improved the most towards this end will be rewarded with social recognition and a ceremony. Half of the eligible clinics in each country (233 in total) are randomly assigned to receive the intervention, while the remaining half serves as control. The objective of the evaluation is to estimate the impact of the intervention on a range of outcomes related to quality of family planning care among young, unmarried, and nulliparous women. We hypothesize that the intervention will improve quality along 3 domains: 1) technical quality (e.g., appropriate counseling and questions asked), 2) patient centeredness (e.g. good treatment of clients), and 3) client outcomes (e.g. client receives appropriate method). We will collect four types of data to evaluate the intervention: 1) provider surveys, 2) mystery clients’ visits, 3) direct observations of client-provider interactions, and 4) qualitative interviews with clients, providers, and implementors.
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After
We evaluate the impact of an intervention designed to reduce family planning provider bias towards young, unmarried, and nulliparous women in Tanzania, Burkina Faso, and Pakistan. The intervention has three components: 1) a summit that highlight the consequences of provider bias and instructions on how not to be biased, 2) a forum for continued communication between providers and implementation staff that reinforces the information from the summit, and 3) a rewards program where facilities in which providers exhibit less biased client interactions or who have improved the most towards this end are rewarded with social recognition and a ceremony. We randomized half of the eligible clinics in each country to receive the intervention and the other half to be a control group. We evaluate the impact of the intervention on a range of outcomes using four types of quantitative data: 1) provider surveys, 2) mystery client visits, 3) client exit surveys, and 4) service provision data routinely collected by the clinics. We report the impact of the intervention on providers’ biased attitudes and beliefs, family planning counseling, family planning methods dispensed, and client perceptions of family planning care. We contextualize our quantitative results with qualitative interviews with key stakeholders, managers, providers, and clients. The document outlines our general analysis plan. This document is in a “rough draft” format but nonetheless pre-specifies our main approach. Some of the writing will be included verbatim in the final paper and thus is written in the past tense (even though most of the work has yet to be performed).
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Trial End Date
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December 31, 2020
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September 30, 2021
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Last Published
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February 11, 2020 01:46 PM
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July 21, 2021 12:30 PM
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Intervention End Date
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October 01, 2020
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August 31, 2021
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Primary Outcomes (End Points)
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Before
We will have different primary outcomes for each domain of interest.
Technical quality outcome(s): Essential questions index and counseling on both short and long acting methods
Patient centered care outcome(s): Patient centered care index
Client outcome(s): Client received modern method and client received long acting method
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After
We will have different primary outcomes for each domain of interest.
Provider Attitudes/Beliefs: Bias index (construction of index outlined in pre-analysis plan)
Patient Centered FP Care: Optimal method counseling
FP Method Received: Received modern method
Perceived Quality of Care: perceived patient centered care index (construction of index outlined in pre-analysis plan)
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Primary Outcomes (Explanation)
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Before
Technical quality: Essential questions index and counseling on both short and long acting methods
For the essential questions index we will aggregate indicators for whether the provider asked about birth spacing preferences, contraceptive method preferences, and if the client had any questions for the provider. This information will be recorded in the exit surveys, provider observations, and mystery client visits. We will use the method outlined by Anderson (2008) to construct the index separately in each data source.
counseling on short and long acting methods will be based on the set of short acting methods, which includes condoms and pills and the set of long acting methods, which includes IUDs, injectables, and implants. If the visit included counseling on at least one method from each set, the visit will be coded as a one (and zero otherwise). This information will be collected in exits surveys, mystery client visits, and provider observations.
Patient centered care: Patient centered care index
The indexed will based on a scale created and validated by Sudhinaraset et al. (2018). We will use questions 37- 44 in the exit survey instrument and identical questions in the mystery client form to construct the index. Each of these questions has a response option of “No, never”, “Yes, a few times”, “Yes, most of the time”, and “Yes, all of the time”. In accordance with the index, we will set each of these 8 questions to 1 if the respondent/mystery client answered “Yes, all of the time” and to zero for all other response. We will then use the Anderson (2008) method to create the index.
Client outcomes: Client received modern method and client received long acting method
These outcomes will be based on two indicators for whether the client received a long acting method or a modern method.
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After
Provider Bias index: This is an index that combines pre-specified question related to bias into one measure. Index will be created using methods outline by Anderson (2008). A complete list of questions that will into the index can be found in the pre-analysis plan.
Optimal method counseling: For mystery clients, optimal counseling should include IUD, Implant, Injectable, and Pill. With real clients assessed using the exit survey, this will be set to 1 if counseled on all methods that fit with the clients preferences. Full set of methods includes IUD, Implant, Injectable, and Pill. If no preferences then they should be counseled on all 4 types. Each preference removed methods from the set. See pre-analysis plan for more details on construction of this measure.
Received modern method: Set to one if received IUD, Implant, Injectable, Pill, condom, emergency contraception, or permanent method
Perceived quality of care: we will aggregate all outcomes related to client perceptions (33 questions) into 1 index using the Anderson (2008) method. See pre-analysis plan for complete list of questions.
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Keyword(s)
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Health
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Health
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Pi as first author
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No
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Yes
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