Quick Investigation of Quality (QIQ) adapted for Antenatal CareTool Name: Quick Investigation of Quality (QIQ) adapted for Antenatal Care Origin / Source: The QIQ was developed by MEASURE Evaluation in collaboration with the Monitoring and Evaluation subcommittee of the MAQ (the USAID funded initiative for Maximizing Access and Quality). The QIQ is designed to monitor the q uality of family planning services. The instruments were adapted to monitor the quality of antenatal care services in Uganda by Charles Katende of the Delivery of Improved Services for Health (DISH) project and Ruth Bessinger of MEASURE Evaluation. Technical Area: Maternal Health Basic Description: Observation guide and exit-interview questionnaire designed to obtain information on antenatal clients visiting health facilities in order to monitor the quality of antenatal care services. Country Applications: The QIQ instruments for family planning have been field tested in five countries: Ecuador, Uganda, Zimbabwe, Turkey, and Morocco. The adaptation of the instruments for antenatal clients was done in Uganda. Language(s) Available: English. Exit Interview Technical Scope/Purpose: The primary purpose of this tool is to monitor the quality of antenatal care services at health facilities. Design: Cross-sectional survey of clients receiving services at health facilities. Method: Quantitative Frequency of Administration: It is recommended that the QIQ be administered every 1-2 years for program monitoring purposes. Key Users of the Information: Managers of reproductive health programs for program monitoring and improvement. Objectives and Scope of the Tool: The objective of the tool is to provide key indicators of quality of antenatal services for program monitoring. The tool consists of two instruments: an observation guide and an exit-interview. The observation of the client-provider interaction is designed to obtain information about the provider's interpersonal skills, information obtained during counseling, the use of screening tools during pregnancy, and practices when conducting a pelvic exam. The exit-interview is designed to obtain the clients' perception of and satisfaction with the services received. Key Indicators: Examples of indicators measuring quality of antenatal care that can be obtained from the tools are as follows: 1) Provider's Interpersonal Skills 2) Information given to client 3) Information obtained from client 4) Physical examination 5) Client satisfaction Tool Design: Program staff should be involved in the planning and implementation of the survey and in the interpretation and dissemination of the findings. Collaboration with district health staff is also crucial to facilitate access to the facilities, to ensure that the survey reflects standard clinical guidelines, and to encourage the use of the results for program improvement. A probability sample of health facilities (or complete census if the number is small) should be selected so that results are representative of the program area. Generally, one day is spent at each health facility and all antenatal care clients who seek services on that day are included in the survey. The time required to complete the survey depends on the number and size of health facilities to be surveyed. In Uganda, a probability sample of 72 health facilities located in 13 districts was included in the survey. This required five weeks of fieldwork plus four additional weeks to complete data entry and conduct a preliminary analysis of the data. It is suggested that data collectors should not be employees of the district health so that the visit to the health facility is not confused with a supervisory visit that includes feedback to management. Implementation and Training: It is advisable to have trained medical providers conduct the observation component of the study. The number of field staff will depend on the number of facilities to be covered and the time frame for data collection. In Uganda, 20 midwives, nurses, clinical officers and advanced medical students conducted the observations of the client-provider interaction, and 20 social workers and sociologists conducted the exit-interviews. All data collection staff was female. Training time averages five days. The first three days include the following: an overview of study objectives and data collection instruments; a question-by-question review of the instruments; role-playing sessions to practice observation and interviewing skills; and discussions of characteristics of good observers and interviewers, data quality issues and protocols for the field. A pre-test is scheduled for the fourth day to provide the field staff with experience in using the data collection instruments, and to identify any problems with the questionnaires. Afterwards, the observers and interviewers meet for a fina l day of training where results of the pre-test are discussed and the instruments finalized. For most health facilities, one interviewer and one observer are sent to each location. When client volume is relatively low, a two-person team is sufficient to survey all clients attending the facility on the day of the survey. For larger facilities, one team is assigned per provider. If client volume is large, additional interviewers may be needed, as the time required to interview the client is longer than the time required to observe the visit. Observers obtain informed consent from the provider and the client for both the observation and the exit interview. A supervisor is assigned three to five data collection teams. Supervisors are responsible for meeting with the local officials, coordinating data collection activities, in the field, and ensuring that data quality remains high. Manuals and Guidelines (if applicable): Guidelines for both the family planning and antenatal care tools are available. Data Processing and Analysis: Data is collected on paper questionnaires in the field. All questionnaires are reviewed by the supervisor before leaving the facility. Local data entry staff enter the data into an Epi-Info database on a daily basis. Data analysis is conducted at the program level using Epi-Info. Reporting and Dissemination of Results (if applicable): Results should be disseminated to program managers and district medical officers if appropriate in the context of the study. Data at the facility level should not be reported to individual facilities unless the tool was administered as part of a supervision exercise. Cost: The cost to implement the tool is affected by both the scope of the study (number of facilities or the size of geographic area to be covered) as well as whether the survey is conducted by project staff or outside data collectors. In the case of Uganda, the survey included 72 health facilities located in 13 districts that required significant travel by field staff. At these facilities, 380 family planning clients and 679 antenatal care clients were observed and interviewed. Five superviso rs and 40 field staff were hired to collect the data over a five-week period. Some donor funding may be required, particularly if the field staff need to be hired to collect the data. Cost could be reduced significantly if project staff serve as data collectors though this does have implications for unbiased monitoring of service provision. Lessons from Experience: The presence of the survey team seems to effect the provider's attitude and conduct with clients. While anecdotal reports indicated that clients were sometimes treated rudely by the providers, all almost all providers observed during the investigation treated the clients with respect. While facility staff was assured that observation records would remain confidential, some providers may have felt that this was a supervisory visit rather than a research activity that wo uld not involve feedback to management. They may have been ill at ease or have put on a show to impress the data collection team, leading to biased observations from the everyday norms. While the observation guide was designed to capture information given during the client-provider interaction, it did not capture any events outside of this meeting. Addition information was given to antenatal clients during group talks, which was not captured by the observation guide. For example, many clients received information on family planning during group talks rather than from the provider during individual counseling. While this information can be picked up in the exit-interview, it is not captured during the observation. Since antenatal clients may make several visits during a pregnancy, it can be difficult to judge the quality of care provided by observing one visit. Certain actions (discussing nutrition during pregnancy or post-partum contraception for example) may have occurred during a previous visit or may be done in a subsequent visit. Contact: |