Development of a client exit survey tool to measure person-centered contraceptive counseling as part of a quality improvement process in Kenyan hospitals

Abstract Background Simple methods and tools that health care facilities can routinely use to measure trends in the quality of family planning (FP) counseling are necessary for applying a quality improvement process. This paper describes the development and testing of a client exit survey tool that is being used by quality improvement teams in 8 hospitals in Kenya to improve FP counseling. Methods A stakeholder consultation was held in Kenya to select questions from existing tools that measure client-reported quality of FP services and were validated or tested in low or middle-income countries. Ten questions were selected: 4 comprising the Person-Centered Contraceptive Counseling (PCCC) measure, 4 comprising the Method Information Index Plus (MII+), 1 comprising the Net Promoter Score, and 1 pulled from the Service Provision Assessment. We then conducted cognitive interviews with 18 women receiving FP services in Kenya to assess their understanding of questions, the face validity of the tool, and client preferences for survey logistics. Results There were mixed results in understanding of PCCC questions, which had not been used in Kenya previously: two were easily understood while two were frequently misunderstood. Respondents generally reported the survey was not difficult to understand and it was not hard to respond to questions. The results of asking participants to rank survey items from most to least important were that PCCC statements ranked most important followed by MII+ items. The Net Promoter Score ranked lowest. Few participants thought questions needed to be added to the tool to capture what they view as quality provider-client interactions. Most participants were unable to select questions for removal. Respondents had differing preferences for how to take the survey, with the most popular mode (8/18) being that the client reads and responds to the survey herself on paper followed by a facility staff member reading the questions aloud and the client recording her responses on paper (5/18). Conclusions A client exit survey tool incorporating the PCCC and MII+ scales seems reasonably understandable and to have good face validity in measuring dimensions of FP counseling important to clients in Kenya.