Integrated delivery of family planning and childhood immunisation services: a mixed methods assessment of service responsiveness

Approximately 218 million women have an unmet need for modern contraceptives in low- and middle-income countries [1], among which postpartum women make up a considerable share [2, 3]. Evidence suggests that the integration of family planning (FP) services with childhood immunisations could help reduce the unmet need among postpartum women by providing repeat opportunities for timely contact with FP services [4]. In some settings, studies have demonstrated that the integration of FP services with childhood immunisations is acceptable to clients and providers, and that it can result in increased contraceptive uptake with little to no negative impact on immunisations [5‐10]. However, research on the integration of these two services has primarily focused on reproductive and behavioural outcomes and less is known about the client experience. This represents an important gap given the established link between the experiential quality of services and both contraceptive uptake and repeat use of health services [11‐16].

A better understanding of the responsiveness of FP services that are integrated with childhood immunisations could help inform the design and implementation of high quality integrated FP services that are client-centred and rights-based [12, 17]. Service responsiveness is concerned with whether the experience of an individual’s interaction with a specific health service fulfils a set of ‘legitimate’ expectations or universally accepted ethical principles and non-clinical service standards [18‐22]. In a review of factors determining the quality of FP services, Tessema et al. identified several studies investigating the quality of FP services that note the importance of responsiveness [23]. Despite this recognition, only two studies have directly investigated the responsiveness of FP services to date. First, a study in Niger demonstrated that low-cost interventions that improve service responsiveness can increase FP uptake when these services are integrated with curative and under-fives consultations [11]. Second, researchers in Sri Lanka developed an instrument to measure the responsiveness of FP services, assessed their responsiveness, and identified its correlates and determinants [24‐26]. According to their research, the domains of responsiveness that are most relevant to FP services are the dignity, environment, choice, communication, confidentiality and ease of access afforded to clients [26].

In 2019, a case study of the responsiveness of FP services that were integrated with childhood immunisations in routine outreach clinics was conducted in Malawi. This case study documented clients’ and providers’ perspectives using mixed methods. The findings presented here comprise the first part of this study, which aimed to assess clients’ experiences of FP services that were integrated with childlhood immunisations and determine the factors associated with perceived responsiveness.

The case study was conducted within a multi-faceted process evaluation carried out in Malawi, Benin, Kenya and Uganda, which interrogated the pathways to outcomes of an NGO-led intervention integrating the delivery of FP services with childhood immunisations in rural areas. In Malawi, the case study took place between June and July 2019 in routine public outreach clinics where the delivery of FP services was integrated into the existing Expanded Programme on Immunisation (EPI), which included childhood immunisations and growth monitoring services.

A cross-sectional convergent mixed methods design was used through which quantitative and qualitative results were combined to generate a comprehensive understanding of clients’ experiences [27]. The selection of this approach was informed by findings from a critical assessment of the WHO’s health systems responsiveness tool, which highlighted the importance of using mixed methods in the assessment of clients’ experiences of outpatient services [28]. Empirical data were collected through clinic audits and exit interviews with clients. Programme monitoring data were also consulted to identify the clinics’ FP client load on the day of the interviews. The methods and results from this study are reported here according to the GRAMMS guidelines for mixed methods studies in health services research [29].

This case study sought to contribute to a deeper understanding of clients’ experiences of FP services that are integrated with childhood immunisations by assessing the responsiveness of these services in terms of eight domains. Overall, the results indicate that in routine outreach clinics, FP services can be responsive when integrated with childhood immunisations, particularly in terms of the dignity and service continuity they afford clients, though less so in terms of the confidentiality, environment, and choice of provider that clients experience. Similar findings were reported by the only other assessment of FP service responsiveness, in which clients in Sri Lanka rated most positively the dignity they experienced and least positively the choice of provider and of contraceptive they were afforded [25]. Despite some lower performing domains, clients interviewed in the case study almost unanimously reported that they would recommend the clinic to a family member or friend interested in FP services. Taken together, these results suggest that the services were likely sufficiently responsive to warrant the repeat use of services, and support the call to integrate FP services with childhood immunisations to reduce the unmet need for contraceptives among postpartum women.

Interestingly, despite being considered most important by clients, the environment and confidentiality were found to be among the responsiveness domains that they rated least postively. This is consistent with findings from the WHO’s general population surveys of health systems responsiveness in which the importance of the environment generally ranked higher among countries with low health expenditure and human development index scores [37]. However, it is possible that the domains considered by clients to be least responsive were also most salient to them, causing clients to rank these among the most important. A notable exception was the choice of provider, which clients’ ranked low both in terms of importance and performance. A possible explanation for this is that clients may not have viewed the choice of provider as a priority given the unmet needs felt in relation to other domains. As De Silva notes, ‘the ability to choose between care providers becomes increasingly important as the other aspects of responsiveness are met’ [18].

Moreover, six of the eight domains’ ratings were found to be significantly associated with several elements of FP counselling and a few client characteristics. Of note, the communication, choice of provider, confidentiality and counselling ratings were positively associated with the exclusive use of one clinic for FP services. This is consistent with findings from Sri Lanka, where clients’ positive responsiveness ratings were associated with using only one FP clinic within the past year [25]. This suggests that experiences with other services may serve as a benchmark and consequently affect clients’ perceptions of the responsiveness of integrated FP services. The influence of a point of reference on clients’ perceptions may also partly explain the unexpected association found in this study between positive ratings of confidentiality and travelling less than 45 minutes to reach the clinic. That is, it is possible that clients who live near a clinic are less likely to seek services elsewhere and thus to have a benchmark, rendering them less critical of the services they experience. Although this is a plausible explanation that is potentially supported by the data, a more conclusive statement cannot be made given the study’s sampling limitations. Further research examining the influence of such a benchmark on perceptions of responsiveness could help improve the delivery of services. Also, contrary to expectations, the clinic’s shelter, number of rooms, and use of space were not significantly associated with clients’ domain ratings, despite results from the cognitive interviewing probes suggesting that infrastructure deficits (e.g., the absence of a suitable shelter) influenced clients’ perceptions of the environment and the confidentiality they experienced. Likewise, counselling ratings were not significantly associated with hearing the group health talk, nor being told how different contraceptives work. It is possible that these two elements of counselling were less relevant to respondents’ perceptions of the counselling domain as the majority of clients interviewed were repeat service users attending the clinics to collect their usual contraceptive method.

The findings also revealed that clients believed that service responsiveness was influenced by the organisation of services in the clinic and the providers’ individual behaviours. Specifically, group-based services were perceived to be less responsive to clients’ needs than one-on-one services in terms of the confidentiality and counselling afforded to clients. Similarly, due to the client flow adopted in the clinics, clients who missed the health talk because they reached the clinic late were deprived from receiving crucial information. Additionally, the pre-determined roles assigned to providers due to the client flow design were believed to prohibit clients’ choice of provider. This echoes recent findings from other empirical studies that demonstrate the important influence of organisational elements on the integrated delivery of FP and childhood immunisation services [9, 10]. It also highlights the value of service designers and implementers adopting a client-centred approach to service organisation in delivery sites. Additionally, the clarity and consistency of the information providers shared with clients, their respect of clients’ choices, the privacy they facilitated, and the professionalism and kindness they exhibited towards clients were found to be central to clients’ experiences. This supports evidence from other studies, including the Integra initiative, which emphasise the crucial role played by providers in the delivery of integrated services and how their individual performance largely determines the success of integration programmes [11, 38‐42].

Furthermore, this study corroborates previous research that established the value of combining cognitive interviewing techniques with Likert questions to test whether questions fulfil their intended purpose [33, 34, 36, 43, 44]; and provides an example of its applicability to the assessment of service responsiveness. The cognitive interviewing probes helped to qualitatively validate the tool used in this study and the clients’ responsiveness scores by confirming that the Likert questions and scale were well understood and accurately interpreted by respondents. The data derived from these probes also yielded important insights into clients’ experiences that would not have otherwise been captured. Using a similar method, Scott et al. demonstrated that Likert questions and scales were not well suited to capturing respondents’ experiences of respectful maternity care in rural northern India [45]. Specifically, they found that Likert response options were often misunderstood, hypothetical questions were commonly misinterpreted, and the translation of standard terms from the literature did not resonate well with respondents in the studied context. It is possible that the successful use of Likert questions in this case study resulted from the approach adopted to refine and pilot the data collection instrument, which was heavily informed by experienced local interviewers. Futher research is needed to examine the applicability of this combination of methods to the assessment of service responsiveness in different contexts.

This study has a few limitations worth noting. First, the exit interviews were susceptible to response biases, such as courtesy and desirability biases. However, the clients’ responses to the cognitive interviewing probes suggest that these biases were likely minimal. Second, in some cases, the providers’ prior knowledge of the researchers’ visit and the presence of the data collection team in the clinics may have prompted providers to alter their delivery of services, rendering them more or less responsive than usual. Third, sub-group analyses and the inferences that could be derived from the quantitative data were restricted by the small sample of clients interviewed. Nonetheless, the findings from the cognitive interviewing probes offer important insights that help mitigate this limitation. And finally, since the study’s primary aim was to assess clients’ experiences of FP services that were integrated with childhood immunisations, comprehensive data were not captured on the growth monitoring services delivered in the studied clinics. This represents an important limitation as the results show that the majority of clients had the intention to seek both growth monitoring and FP services on the day of the exit interviews, which was likely due to the more frequent need for these services compared to scheduled immunisations.

This case study set out to investigate clients’ experiences of FP services that were integrated with childhood immunisations in routine outreach clinics. In doing so, it also demonstrated the value of combining cognitive interviewing techniques with Likert questions to assess service responsiveness. The results from this study establish that in routine outreach clinics, FP services can be responsive when integrated with childhood immunisations, particularly in terms of the dignity and service continuity they afford clients, though to a lesser extent in terms of the confidentiality, environment and choice of provider experienced. The clients’ views of the choice of provider, communication, confidentiality and counselling they experienced were found to be positively associated with the exclusive use of one clinic for FP services, suggesting that having a benchmark may have an important influence on perceptions of responsiveness. The findings also highlight the influence of the organisation of services and of the providers’ individual behaviours on service responsiveness. Further research is therefore needed to interrogate the views of providers and their influence on the responsiveness of FP services that are integrated with childhood immunisations.