Background
Strengthening family planning services is crucial to improving health, human rights, economic development and slowing population growth.1 Effective family planning is identified as one of the top ten public health achievements of the United States during the 20th century.2 However, an estimated 225 million women who want to avoid pregnancy are not using safe and effective family planning methods for various reasons including lack of access to information or services and lack of support from their partners or communities. The majority of these women with an unmet need for contraceptives live in 69 of the poorest countries. This unmet need is fueled by both growing population and a shortage of family planning services.3,4 In the last two decades, the contraceptive prevalence among married, reproductive-aged women has increased worldwide. Globally, contraceptive prevalence rose from 55% in 1990 to 63% in 2010.5 However, the unmet need for contraception has remained high in developing regions.6 In 2013, only about a quarter of married women were practising family planning in Africa.7
Increasing access to family planning services is widely recognized as a priority public health issue at an international level. A number of global partnerships, including the International Conference on Population and Development in 1994,8 the Millennium Development Goal summit in 20009 and the London Summit on Family Planning in 2012, endorsed a global partnership known as Family Planning 2020 aimed to enable 120 million more women to use contraceptives by 2020 in 69 of the world's poorest countries.10
Improving the quality of care in family planning services is known to be key to improving the use of family planning services in developing countries, both by attracting new contraceptive users and by maintaining existing users (i.e. ensuring continued engagement with services).11-18 Providing decision makers in developing countries, including Africa, with the best available evidence on the factors that determine the quality of care in family planning services from the perspective of clients and healthcare providers is important to ensure the design and implementation of the most effective, efficient and acceptable quality improvement measures.
In this protocol and systematic review, family planning services is defined as the provision of counseling on contraceptive methods and/or provision of contraceptive methods including insertion of intrauterine devices, surgical sterilization services or prescription of contraceptive methods, in circumstances where the methods are not available.19-21
Initial searching of the literature relating to quality of care in family planning services in Africa, low- and middle-income countries and the rest of the world revealed that researchers have used various approaches to define and measure quality of care in family planning services. The definition and measurement of quality of care might vary based on the stakeholders' priorities and various perspectives.22 The Donabedian model and Bruce Framework have been the most frequently used approaches, at least since 1990, to inform studies assessing and describing the quality of family planning services.
Donabedian defined quality of care as "the application of medical science and technology in a manner that maximizes the benefits to health without correspondingly increasing the risk".23(p.5) This model is intended to assess quality of care in various health services including family planning. He identified quality of care as a linear model comprising the three components - structure, process and outcome. The structure dimension includes all factors affecting the conditions of care such as budget, staff training, reward systems, payment methods, facilities and equipment. The process dimension focuses on the providers communication with the client including the client-provider relationship. The last component is the outcome following provider and client interaction in the healthcare delivery site. This includes the client's satisfaction, change in knowledge and other subsequent long-term aspects such as reduction in fertility and mortality. These three parts are interlinked in the model, with good structure presented as increasing the likelihood of good process and good process as increasing the likelihood of a good outcome.23,24
Based on the Donabedian model, Bruce and Jain developed a framework assessing the quality of care in family planning services. They identified six elements for quality of care in family planning programs that they propose to "reflect the six aspects of services that clients experience as critical". These six elements form the Bruce Jain Framework for assessing quality of care in family planning. The elements are (1) choice of methods, (2) information given to clients, (3) technical competence of providers, (4) interpersonal relations, (5) follow-up mechanisms and (6) appropriate constellation of services.25 The "Choice of Methods" refers to having a range of contraceptive methods offered to the clients considering their diverse needs influenced by age, gender, contraceptive intention, lactation status, health profile and wealth status. "Information given to clients" refers to the information provided to clients during service interactions that enables clients to choose and use contraception with competence and satisfaction. This includes information about a range of available contraceptive methods, method contraindications, method advantages and disadvantages, how to use the selected method, potential side effects and continuing care from service providers. The "Technical Competence" aspect involves providers' clinical techniques, use of protocols and implemention of aseptic procedures in clinical conditions. "Interpersonal relations" refers to the degree of empathy, trust, assurance of confidentiality and sensitivity of providers to meet the client's needs and expectations. The "Follow-up Mechanism" covers how service providers encourage clients on the continuity of use through well informed mechanisms such as community mass media, client-based follow-up mechanisms (return appointments) or home visits. The last component, "Appropriate Constellation of Services", refers to the extent to which family planning services are situated in convenient and accessible locations. This includes their accessibility (distance, timing and cost) and the level of integration with other reproductive and maternal health services.
Empirical studies have shown facility-related factors such as managing authority (public or privately owned), availability of a variety of methods and waiting time 21,26-29 as being associated with quality of care in family planning services. Client-related factors such as age, educational status and client types (new versus repeat)30,32 have also been identified in the existing empirical research as associated with quality of care in family planning services. In addition, provider-related characteristics such as sex, year of experience and level of education have been identified as factors associated with the quality of care in family planning services.31,32 Overall, the findings indicate that there are no consistent results across studies.
The cursory search of the literature undertaken to inform this protocol identified three systematic reviews addressing the question of quality of care in family planning service and its determinants. All three included only studies conducted in the United States.31,33,34 The preliminary literature search identified six primary studies19,21,30,35-37 conducted in Africa examining the determinants of quality of care in family planning services. Two of the studies used qualitative method35,37 and four used quantitative methods.19,21,30,36 Two studies were conducted in Ethiopia,30,36 one in Kenya,35 one in Uganda37 and two studies19,21 were undertaken in various other African countries. No systematic review of the quantitative, qualitative evidence, or both, on the factors determining quality of care in family planning services in any African countries was identified.
The proposed systematic review is intended to fill the gap in the systematic review evidence base on the determinants of or factors contributing to the quality of care in family planning services in African countries. It should provide policy makers and healthcare practitioners working in Africa with evidence that can be used to develop strategies that enhance the quality of care in family planning services.
This review is being conducted as part of the lead author's doctoral research. One intention of the review is also to inform further primary research on the level and determinants of quality of care in family planning services in Ethiopia to be undertaken by the lead reviewer.
Inclusion criteria
Participants
Participants considered for inclusion in this review are clients and/or providers of family planning services in any African country. Female and male clients and providers of all ages, any socio-economic status and from all ethnic and language groups will be considered. Clients and providers of family planning services at all levels (e.g. lower or higher level) and types (public or private) of health services will be considered.
For the quantitative evidence
Exposure of interest
Studies that investigate factors including facility, client and provider characteristics associated with quality of care in family planning services in Africa will be considered for inclusion.
The client characteristics (exposures) will include socio-demographic characteristics of the clients using family planning (age, sex, marital status, education, religion and income).
The facility characteristics (exposures) will include ownership (public versus private), availability of equipment, infrastructure availability and quality, ownership of the facility, follow-up mechanisms and services constellations.
The provider characteristics (exposures) will include factors such as the provider's age, sex, level of education, training and presence of supervision. These factors will be considered as determining factors if there is a report showing the relationship between them and client satisfaction.
Family planning services is defined as counseling on contraceptive methods and/or provision of contraceptive methods including insertion of intrauterine devices, surgical sterilization services or prescription of contraceptive methods in circumstances where the methods are not available.
Outcomes
Client satisfaction in family planning services is the outcome of interest. To be included studies must either have (1) assessed client satisfaction using proxy questions such as satisfaction with waiting time, privacy, availability of family planning methods, cleanliness of the facility, costs of the services, the staff treatment and developed one aggregate variable using principal component analyses to present the measure as a continuous variable or dichotomized as satisfied or not satisfied or (2) assessed client satisfaction using a Likert scale in five categories from poorest satisfaction to highest satisfaction and calculated a mean score to dichotomize the variable.
Types of studies
All quantitative study designs will be considered. It is anticipated that most will be observational studies. The quantitative components of mixed method studies will be considered.
For the qualitative evidence
Phenomenon of interest
The phenomenon of interest is client and provider experiences and/or perceptions of the factors that determine quality of care in family planning services.
Family planning services is defined as counseling on contraceptive methods and/or provision of contraceptive methods including insertion of intrauterine devices, surgical sterilization services or prescription of contraceptive methods in circumstances where the methods are not available.
Context
Studies conducted in Africa, published from 1990 onward.
Types of studies
All qualitative study designs will be considered including qualitative components of mixed method studies. To be defined as qualitative study, the authors must have reported their data collection and analysis methods.
Methods
Search strategy
Studies in English published from 1990 onward will be included (including peer-reviewed articles and gray literature). The start date, 1990, was selected for the search because it is the year when quality of care began to be emphasized in family planning services.25,38,39
We will use the three-stage search strategy recommended by the Joanna Briggs Institute (JBI).40 First, limited search will be done in PubMed and Cumulative Index of Nursing and Allied Health Literature (CINAHL) using few keywords, and then the text words in the titles, abstracts and the index terms will be assessed. Second, a comprehensive search will be undertaken using all identified keywords and index terms across all included databases, websites and search engines. Third, the reference lists of the articles that will be selected for critical appraisal will be searched for studies matching the inclusion criteria. In addition, researchers and healthcare providers known to the lead reviewer who work in family planning service policy and delivery in Ethiopia will be contacted for relevant studies that may have been missed in the search.
In the searching process, the databases such as PubMed, CINAHL, EMBASE, Scopus, POPLINE the Cochrane Collaboration reports of controlled trials, African Index Medicus and Web of Science will be searched. Furthermore, key search engines such as Google, Google Scholar, World Bank, World Health Organization, Family Health International, International Planned Parenthood Federation and the DHS program website will be searched specifically for gray literature.
A librarian from University of Adelaide with specialist expertise in searching databases for systematic reviews will be consulted on the search strategies for each of the databases. The reviewed studies that potentially match the inclusion criteria will be exported to Endnote. An Endnote database of the abstract records of studies identified as potentially matching the inclusion criteria will be created and used for the study selection. Citations identified through the search strategy will be initially reviewed for inclusion based on information contained in titles, abstracts, citation information and keywords by the principal investigator. The relevant citations will then be independently screened by two reviewers to determine eligibility. Following this, full-text articles will be obtained for all eligible studies and for those requiring further review to determine eligibility. Articles that, on full-text examination, do not match the inclusion criteria will be excluded, and the reasons for exclusion will be noted. Those articles that fulfill the inclusion criteria will be critically appraised and included in the review.
The following key terms will be used for the initial search: quality of care, quality of healthcare, health care quality, satisfaction, family planning services, family planning, contraceptive services, contraception, Africa and the names of each African country.
Assessment of methodological quality
Studies matching the inclusion criteria for the reviews will be assessed using the most appropriate tool from the suite of critical appraisal tools in the JBI System for the Unified Management, Assessment and Review of Information. More specifically, studies contributing quantitative evidence will be appraised using the most appropriate instrument from the JBI Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Studies contributing qualitative evidence will be appraised using the tool in the JBI Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix II). Two reviewers will critically appraise the included studies and work independently. Any disagreements will be resolved by discussion with all review authors. The appraisal for cohort/case-control and descriptive studies includes nine items with a yes/no/unclear response option: the "Yes" will be scored "1", "No" or "Unclear" will be scored "0". Articles will be scored as follows: low quality (0-3), moderate quality (4-6) and high quality (7-9). The appraisal tool for interpretive and critical research includes 10 items, and qualitative articles will be scored as low quality (0-3), moderate quality (4-6) and high quality (7-10).
Data extraction
The JBI-MAStARI data extraction tool (Appendix IV) will be used to extract data from included quantitative studies, and the JBI-QARI data extraction tool (Appendix III) will be used to extract data from included qualitative studies. Two types of data will be extracted. First, descriptive data which will include citation details and study objective, population and setting, details on the family planning interventions(s), study methods/design including how the quality of care in family planning service was defined and any limitations identified by the study authors in this regard. Second, from the qualitative studies, the findings about how client and providers perceive the factors that determine the quality of care in family planning services, and from the quantitative studies the measures on the factors of the quality of care family planning services. Due to both the possibilities that client satisfaction could be taken as either categorical or continuous variables in the measurement, adjusted odds ratio or regression coefficient ([beta]) of the factors affecting quality of care as measured by client satisfaction will be collected, respectively. In addition, data on possible confounder factors will be sought to be included.
Data synthesis
Quantitative data will, where possible, be pooled in statistical meta-analysis using RevMan Software.41 Effect sizes expressed as odds ratio for categorical data and mean difference for continuous data, and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard chi-square and I2 tests and also explored using subgroup analysis. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.
The JBI meta-aggregation approach will be used to synthesize findings from the qualitative studies. This will involve first the aggregation of findings into categories based on similarity of meaning and then developing synthesized findings from the categories.
Appendix I: JBI Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) study appraisal tools
Appendix II: JBI Qualitative Assessment and Review Instrument (JBI-QARI) study appraisal tool
Appendix III: JBI-QARI data extraction tool
Appendix IV: JBI-MAStARI data extraction tool
References