A Review of the HHS Family Planning Program Mission, Management, and Measurement of Results (2009) / Chapter Skim
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Appendix K: Measurement of Quality in the Title X Family Planning Program
Appendix K: Measurement of Quality in the Title X Family Planning Program
Pages 407-458
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From page 407... ...
The Title X program mandate specifies three long-term measures that are to be reported annually: (1) increasing the number of unintended preg 407
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-- Percent clients still using any method -- Percent referrals for pregnancy termination or percent referrals for prenatal care for unintended pregnancy -- Percent pregnant who desired pregnancy • Patient-specific evaluation of the quality of information provided -- Technical competence and interpersonal skills of provider -- Client comprehension (health literacy) This appendix addresses the measurement of the quality of reproductive health services provided under the Title X program.
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From page 409... ...
Surprisingly, the lack of data on the quality of family planning services in the United States in general and under Title X in particular is not due to the lack of an evidence base for indicators, but to an apparent failure to capitalize on the extensive work that has been done and applied internationally in this arena. Similarly, and not surprisingly, the dearth of quality-of-care research in the area of family planning in the United States contrasts with the quality-of-care work in the medical/surgical arena, likely because family planning has historically been focused primarily on women.
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From page 410... ...
Similarly, focused incorporation of selected indicators from the Handbook of Indicators for Family Planning Program Evaluation, which contains more than 200 indicators, would be beneficial and could elevate family planning and preventive reproductive health services in general, and the Title X program in particular, from a relatively obscure program for the poor to a more prominent national program dedicated to improving the health and well-being of women, children, and families (Bertrand et al., 1994)
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. Further analysis of the merits of the Title X program is needed using various methodologies, such as provider observation or simulated patients, to document technical competence and communication skills.
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These tools, coupled with standardized protocols, could be shared across state and federal agencies, including STD clinics and public schools, as well as incorporated into medical, nursing, and residency training curricula. There is clearly stakeholder support for enhancing the quality of family planning services at the user/provider level, but broader support at the administrative and policy levels is needed to facilitate the development of a national agenda emphasizing the maternal, child, and family benefits of family planning and preventive health services in general and the Title X program in particular.
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. Key representative variables critical for assessment of the quality of Title X programs using the various domains outlined by Donabedian are shown in Figures K-1 through K-3.
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FIGURE K-2 Services that must be provided by Title X programs. Structure Process Outcome Donabedian Effect Input Processes Output Outcome Impact Program Evaluation PROGRAM POPULATION FIGURE K-3 Similarities between quality monitoring and program evaluation.
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. The federal Family Planning Program is authorized under Title X of the Public Health Service Act, which was created in 1970 to provide family planning and related preventive health care.
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However, the program has been in existence long enough to be capable of demonstrating long-term impact if the correct data are made available for collection and interpretation. International Frameworks for Quality Family Planning Services Several authors have published extensively on quality assessment as it relates to the international family planning and reproductive health care arena.
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define eight broad categories for program evaluation, which outline the pathways by which programs achieve impact in a given country: • Indicators to measure the policy environment, • Indicators to measure service delivery operations, • Indicators to measure family planning outputs, TABLE K-1 International Planned Parenthood Federation Framework: Clients' Rights and Providers' Needs Client Rights Provider Needs Information about family planning Training -- technical and communication skills Access to all service delivery systems and Information on technical issues updated regularly health care providers Choice of adopting, switch, or discontinuing Infrastructure (appropriate facility and efficient methods organization) Safety in the practice of family planning Supplies of contraceptives, equipment, and educational materials Privacy during discussions and physical Guidance from service guidelines, checklists, and examinations supervision Confidentiality of all personal information Back up from other providers Treated with dignity, courtesy, and Respect and recognition from coworkers, attentiveness managers, clients, community Comfort while receiving services Encouragement to provide good quality care Continuity of care for as long as client Feedback from managers, supervisors, and clients desires Opportunity to express opinions about he Opportunity to express their concerns relative to quality of care received clinic decision making Source: Huezo, C
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(1994) advise that a key prerequisite for the development of a successful family planning program is the presence of a strong, viable political and administrative system.
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Chapel Hill, NC: MEASURE Evaluation, Carolina Population Center. http://www.cpc.unc.edu/measure/publications/pdf/ms-94-01.pdf (accessed April 18, 2008)
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X X I-6 • Discusses dual method use X X I-7 • Treats client with respect/courtesy X X I-8 • Tailors key information to the particular needs of the X specific client I-9 • Gives accurate information on the method accepted X X (how to use, side effects, complications) I-10 • Gives instructions on when to return X X I-11 Follows infection control procedures outlined in X guidelines I-12 Recognizes/identifies contraindication consistent with X guidelines I-13 Performs clinical procedures according to guidelines X STAFF (other than provider)
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5. Chapel Hill, NC: MEASURE EVALUATION, Carolina Population Center.
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. Recently, assessment of family planning program quality has begun to emphasize client satisfaction.
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There is limited information on costs, cost-effectiveness, and financing. To summarize, the international literature has established the following tenets as the elements essential for quality family planning services: • A client-centered perspective sets the program objectives and standards.
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. An explicit understanding of national population/fertility goals is critical to judging the success of the Title X program.
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It provides an estimate of the impact of Title X–funded activities on key reproductive health outcomes. The Research Triangle Institute (RTI)
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Variables Staffing. In 2006, there were 3,937 FTEs working at Title X sites, including physicians, midlevel providers, and other clinical service providers (CSPs)
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Female Users by Primary Contraceptive Method at Last Encounter in Reporting Period. In 2006, 85 percent of Title X clients were using a contraceptive method, while 15 percent were not (8 percent seeking pregnancy, 7 percent other reasons)
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. It addresses the Title X mission to decrease cervical cancer, and there is an existing benchmark.
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and Gender In 2006, Title X clinics tested 47 percent of all female users and 52 percent of male users for chlamydia. Testing rates were highest among younger users.
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This section starts with a broad overview of the utilization of family planning services and quality assessment studies of family planning programs in the United States. It then reviews what is known about the quality initiatives that have been undertaken by Title X programs, as evidenced by the PART and the proposed FPCA Performance Measurement System (FPCA, 1999; OMB, 2005)
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This change is due mainly to an increase -- from 22 percent to 67 percent -- in the proportion using the male condom at first intercourse, and likely reflects heightened concern about and awareness of HIV/STD prevention. This finding supports the programmatic impact of Title X and other family planning initiatives.
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, and further validate Title X ‘s mission. More than 44 million women obtained reproductive health services in 2002.
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performed a systematic literature review to examine the relationship between family planning services and safe and effective contraceptive use (Paine et al., 2000)
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The studies were not limited to Title X programs. The methodology most commonly used in the studies reviewed was surveys of women receiving the services.
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. Ideally, this would not be an issue in Title X clinics, based on statutory requirements, but objective performance data are needed to confirm this.
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Hospitals and health departments received the poorest ratings from clients, while private physicians received the highest ratings. This contradicts other find ings since hospitals and health departments are more likely to be Title X sites providing more comprehensive services, but they may also have longer waiting times, more rigid hours, and other admin istrative barriers.
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Further, the authors suggest increased utilization of expert observations in the field, chart audits, simulated patient visits, and provider surveys to provide a more informative, multidimensional measure of quality at the site. While most studies of family planning services have focused on users, examining reasons for nonuse may reveal unfavorable perceptions of services within the community or provide insight into the role of ambivalence and pregnancy intendedness.
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From page 438... ...
increasing the number of unintended pregnancies averted by providing Title X family planning services, with priority for services to low-income individuals; (2) reducing infertility among women attending family planning clinics by identifying chlamydia infection through screening of females aged 15–24; and (3)
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Reveal About the Quality of the Title X Program? In 1999, in the absence of a national set of family planning indicators, FPCA decided to develop a measurement system to assess the performance of Title X grantees and delegate agencies within the FPCA network of family planning service delivery (FPCA, 1999)
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Cursory discussions with two clinic sites corroborated these lessons with the following caveats. Data collection was perceived as burdensome by one site, taking CPSs away from other family planning services.
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A review of the literature reveals that a theoretical framework and a multitude of quality indicators exist that can be used to assess the quality of family planning and reproductive health services in the Title X program. One can think of the indicators presented as a pyramid becoming more complex and more comprehensive as one approaches the base (see Figure K-6)
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activities. ments, increased volume, program revenues, technical competence, and Figure K-4 patient satisfaction.
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While the presumed benefits are clear, the opportunity now exists to demonstrate the quality of family planning services within the Title X program definitively and establish a causal link with reproductive health outcomes. The American public needs to learn to plan for pregnancy from puberty on, and to acquire the skills necessary to achieve personal reproductive goals.
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Birth spacing • 9.3. Contraceptive use -- Contraceptive failure -- Emergency contraception -- Male involvement with pregnancy prevention -- Adolescent pregnancy -- Abstinence before age 15 -- Abstinence ages 15–17 -- Pregnancy prevention and STD protection -- Pregnancy prevention education -- Problems in becoming pregnant -- Insurance coverage for contraceptive supplies and services There are also 19 Healthy People 2010 objectives related to STDs (see Annex Table K-2)
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APPENDIX K 445 ANNEX TABLE K-1 Healthy People 2010 Reproductive Health Objectives with Targets and Baselines Topic Objective Target Baseline Intended Increase percent of 70 percent 51 percent pregnancy pregnancies that Note: 39 percent in Canada, are intended 6 percent in Netherlands Spacing Reduce percent of 6 percent 11 percent births occurring within 24 months of a previous birth Contraceptive Increase use 100 percent 93 percent used use People who do not use any method account for half of unintended pregnancies; rest occur to those who use intermittently or incorrectly Contraception Reduce proportion 7 percent 13 percent failure of females Focus on consistent and experiencing correct use of a specific pregnancy despite method use of a reversible contraceptive method Emergency Increase percent of Emergency contraception can contraception health care reduce risk of pregnancy by (developmental) providers that 75 percent; in 1995, fewer provide emergency than 1 percent of women contraception reported using emergency contraception; need direct access and insurance reimbursement continued
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446 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM ANNEX TABLE K-1 Continued Topic Objective Target Baseline Male Increase male Need to be Men make up 10 percent of involvement involvement in culturally and total clientele in only with pregnancy pregnancy linguistically 13 percent of clinics; an prevention prevention and sensitive in average of 6 percent of (developmental) family planning promoting clients are male -- only efforts condom use and 2 percent of Title X clients in addressing HIV 1991 and 2 percent of and STD Medicaid clients in 1990 prevention, managed care marketing; emphasis on male responsibilities regarding welfare, need for rapid treatment of female partners who test positive for bacterial STD to decrease STDs, including HIV Adolescent Decrease 43/1000 68/1000 pregnancy Abstinence Increase percent of Females Females 62 percent; males before age 15 teens who have 75 percent; 57 percent never engaged in males 75 percent The later intercourse starts, intercourse the less overall exposure; need education regarding intimacy; setting limits; and resistance to social, media, peer, and partner pressure Dual protection Condoms: females Condoms: females at ages 15–17 75 percent, males 67 percent, males 72 percent; at first 83 percent; condoms +: females intercourse condoms +: 7 percent, males 11 percent females 9 percent, Condom use has increased, males 11 percent suggesting that teens do anticipate and plan for initiation; decrease in hormonal treatment
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From page 447... ...
maintenance organizations covered contraception in 1993; methods inconsistent; bias toward permanent surgical methods • Responsible teen sex -- Increase percent of adolescents who abstain from sex or use condoms if active. • Responsible sex on television (developmental)
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minimize the (developmental) number of high-risk subtypes associated with cervical cancer)
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related to responsible sexual behavior on television Hepatitis B vaccine Increase number of 90 percent 5 percent in STD clinics STD programs that offer hepatitis B vaccine Screening in Screen within detention and jails 24 hours of (developmental) admission and provide treatment before release Contracts to treat Increase percent of nonplan partners local health (developmental)
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-- Increase percent of pregnant women screened for STD, HIV, and (BV)
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I Policy Environment • Existence of a policy development plan • Number of appropriately disseminated policy analyses • Number of awareness-raising events targeted to leaders • Existence of a strategic plan for expanding the national family planning program • Integration of demographic data into development planning • Number of statements of leaders in support of family planning • Formal population policy addressing fertility and family planning • National family planning coordination • Level of the family planning program within the government administration • Levels of import duties and other taxes • Restrictions on advertising of contraceptives in the mass media • Absence of unwarranted restrictions on providers and users • Quality of program leadership • Extent of commercial-sector participation II.
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stocked according to plan • Percentage of key personnel trained in contraceptive logistics • Composite indicator for commodities and logistics VI. Information–Education–Communication • Number of communications produced, by type, during a reference period • Number of communications disseminated, by type, during a refer ence period • Percentage of target audience exposed to program messages, based on respondent recall • Percentage of target audience who correctly comprehend a given message • Number of contraceptive methods known • Percent of audience who acquire the skill to complete a certain task as a result of exposure to a specific communication • Percentage of target audience exposed to a specific message who report liking it • Number/percentage of target audience who discuss message(s)
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-- Percentage of target population favorable to the (national) family planning program • Service Utilization -- Number of visits to SDP(s)
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454 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM -- Number of acceptors new to the institution -- Number of new acceptors -- Couple-years of protection (CYP) -- Method mix -- User characteristics -- Continuation rates • Contraceptive Practice -- Contraceptive prevalence rate (CPR)
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2006. Each $1 invested in Title X Family Planning program saves $3.80.
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2000c. Healthy people 2010 -- Reproductive health.
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2003. The quality of family planning programs: Concepts, measurements, interventions and effections.
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2007. Assessing the quality of reproductive health services in Egypt via exit interviews.
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