Measuring Service Quality and Assessing Its Relationship to Contraceptive Discontinuation: A Prospective Cohort Study in Pakistan and Uganda

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FIGURE 1.
Adapted Facility-Level Quality of Care Framework
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FIGURE 2.
Cumulative Probability of Modern Method Discontinuation Among Women in Need in Pakistan and Uganda

TABLE 1.

Descriptive Statistics and Cronbach’s Alpha Scores for Each Facility Quality Domain in Pakistan and Uganda

Domain	Pakistan							Uganda
			Range							Range
	Score Range	No. of items (N=36)	Min	Max	Mean (μ)	SD(σ)	Alpha(α)	Score Range	No. of items (N=20)	Min	Max	Mean (μ)	SD (σ)	Alpha(α)
Readiness for choice	0–14	7	5.42	14.00	12.20	1.94	.70	0–2	1	1.00	2.00	1.50	0.51	n/a^a
Readiness for management support	0–12	6	1.77	11.83	8.02	2.88	.84	0–10	5	5.00	10.00	8.90	1.81	.89
Client-centered readiness	0–7	4	0.00	6.92	4.06	1.57	.66	0–6	3	3.00	6.00	5.07	1.17	.79
Interpersonal skills	0–8	4	0.67	8.00	5.49	1.94	.90	n/a^b
Technical competence	0–22	11	3.64	21.53	15.69	4.01	.80	0–10	7	7.00	14.00	11.83	2.41	.83
Information provision	0–6	3	0.00	6.00	2.97	1.91	.97	0–8	4	1.00	8.00	6.20	2.02	.65
Structural privacy^c	0–2	1	0.00	2.00	1.45	0.61	n/a^a	n/a^c

Abbreviations: n/a, not applicable; SD, standard deviation.
↵a The structural privacy variable in Pakistan and the readiness for choice domain in Uganda each contained only 1 item; alpha not calculated.
↵b No variables were grouped into the interpersonal skills domain in Uganda.
↵c The structural privacy variable did not group well with variables in other domains in Pakistan. In Uganda, the structural privacy variable was included in the client-centered readiness domain.

TABLE 2.

Unadjusted and Adjusted Hazard Ratios for Discontinuation of Modern Contraception in Pakistan, by Quality Domain

	Unadjusted Univariate ModelModel 1		Unadjusted Full ModelModel 2		Adjusted Reduced Model^aModel 3
Facility Quality Domain	HR (95% CI)	P-value	HR (95% CI)	P-value	HR (95% CI)	P-value
Readiness for choice	0.89^b (0.77, 1.03)	.10	0.94ⁱ (0.81, 1.10)	.43	0.92^j (0.80, 1.05)	.20
Readiness for management support	1.02^c (0.90, 1.15)	.77	0.91ⁱ (0.76, 1.09)	.30
Client-centered readiness	1.14^d (0.90, 1.44)	.27	1.23ⁱ (0.92, 1.65)	.16
Interpersonal skills	0.80^e (0.69, 0.92)	.002	0.97ⁱ (0.76, 1.25)	.83
Technical competence	0.92^f (0.86, 0.98)	.008	1.00ⁱ (0.90, 1.11)	.99
Information provision	0.79^g (0.68, 0.91)	.001	1.06ⁱ (0.79, 1.42)	.72
Structural privacy	0.37^h (0.24, 0.57)	<.001	0.36ⁱ (0.18, 0.71)	.003	0.40^j (0.26, 0.61)	<.001
Age category (35–49, ref)					—	—
15–24					1.96 (1.01, 3.78)	.05
25–34					1.70 (1.02, 2.83)	.04
Use short-acting method					1.80 (1.14, 2.86)	.01

Abbreviations: CI, confidence interval; HR, hazard ratio; ref, reference category; SE, standard error.
↵a Adjusted for participants’ age and short-acting versus long-acting method use at baseline.
↵b Theta (shared frailty term): t=0.88, SE=0.33, P<.001.
↵c Theta (shared frailty term): t=0.99, SE=0.35, P<.001.
↵d Theta (shared frailty term): t=0.98, SE=0.34, P<.001.
↵e Theta (shared frailty term): t=0.68, SE=0.28, P<.001.
↵f Theta (shared frailty term): t=0.72, SE=0.30, P<.001.
↵g Theta (shared frailty term): t=0.63, SE=0.29, P<.001.
↵h Theta (shared frailty term): t=0.47, SE=0.23, P=.001.
↵i Theta (shared frailty term): t=0.44, SE=0.22, P=.001.
↵j Theta (shared frailty term): t=0.55, SE=0.27, P<.001.

TABLE 3.

Unadjusted and Adjusted Hazard Ratios for Discontinuation of Modern Contraception in Uganda, by Quality Domain

	Unadjusted Univariate ModelModel 1		Unadjusted Full ModelModel 2		Adjusted Reduced Model^aModel 3
Facility Quality Domain	HR (95% CI)	P-value	HR (95% CI)	P-value	HR (95% CI)	P-value
Readiness for choice	0.79 (0.42, 1.47)	.46	0.59 (0.28, 1.23)	.16
Readiness for management support	0.96 (0.82, 1.13)	.64	0.60 (0.42, 0.86)	.005	0.67 (0.51, 0.89)	.005
Client-centered readiness	1.05 (0.78, 1.41)	.76	1.30 (0.92, 1.82)	.13
Interpersonal skills	—	—	—	—	—	—
Technical competence	1.07 (0.91, 1.25)	.43	1.47 (1.07, 2.02)	.02	1.32 (0.97, 1.78)	.07
Information provision	1.03 (0.89, 1.18)	.73	1.05 (0.87, 1.25)	.64
Age category (35–49, ref)						—
15–24					1.93 (0.62, 6.03)	.26
25–34					2.54 (1.01, 6.39)	.05
Use short-acting method					7.64 (3.91, 14.92)	<.001

Abbreviations: CI, confidence interval; HR, hazard ratio; ref, reference category.
↵a Adjusted for participants’ age and short-acting versus long-acting method use at baseline.