TABLE 2.

Evolution of Survey Items to Measure Authoritarian Provider Attitudes in Democratic Republic of Congo and Togo

Item No.	Phase 1	Phase 2	Problems Found in Phase 2	Phase 3 Fielded Version
Providers' attitudes associated with their perceptions of clients
1	Patients I care for are not educated enough to make good health decisions for themselves.	No change	Question requires more subjectivity to reflect an attitude (i.e., capability vs education).	Patients I care for are not capable of making good health decisions for themselves.
2	Patients I care for are not grateful for the efforts I make when I care for them.	Patients I care for are not grateful for the efforts I make when I care for them.	Question requires more subjectivity to reflect an attitude (i.e., should).	Patients I care for should appreciate my efforts when I care for them.
3	I consider my patients to be worthy of respect no matter how poor or low status they are (low response variability).	Dropped	Dropped	Dropped
4	Patients often treat me without respect, so it's hard to treat them with respect (low response variability and double-barrel statement).	It's hard to treat patients with respect if they don't treat me with respect.	Low variability in phase 1 quantitative test. Question requires more subjectivity to reflect an attitude (i.e., should) and test variation focused on client's behavior.	a. One should treat patients with respect even if they don't treat me with respect. b. Patients must always respect providers, regardless of the quality of care they receive.
5	Patients I care for make bad decisions regarding their health no matter what I tell them.	No change	Question wording requires an element of judgement to reflect an attitude.	My patients don't listen to my advice no matter what I tell them.
6	My patients will work hard to improve their health when they are given the proper information.	My patients will put a lot of effort into improving their health if they are given the right information.	No change needed.	My patients will put a lot of effort into improving their health if they are given the right information.
Providers' attitudes about their professional role
7	My role is to provide clinical care, not to teach patients about how to take care of themselves.	A provider's role is to provide clinical care, not to teach patients about how to take care of themselves.	More specificity.	A provider's role is to diagnose patients and provide clinical care, not to teach patients how to improve their health and prevent disease.
8	I do not spend a lot of thought about what patients may think about their experience at the clinic as I have other things to worry about.	No change	Frame in terms of responsibility, add more precision.	My responsibility is to diagnose and ensure appropriate treatment, not ensure they have a pleasant experience at the clinic.
9	An important part of my job is to communicate with patients to make sure they understand their care (low response variability).	An important part of success at my job is to communicate with patients to make sure they understand their care.	Low variability but no clear alternative based on CI. Testing out variations that test bidirectional communication and holistic view of HCP role.	a. I have the responsibility to ensure that patients have a say in their care. b. It is important to listen to patients to ensure they understand their care. c. It is my role to think about other elements of health care services, not just diagnosis and treatment.
10	I try hard to think about all of the patients' health care needs not just solving their immediate problem.	No change	Inconclusive CI result. Retest item, plus test wording framed as providers' responsibility.	a. I make an effort to think about all my patient´s needs regarding medical care, not just the immediate health problem. b. My role as a provider is to resolve my patients' immediate medical problems, and nothing else.
11	I was trained to provide clinical care, being respectful to every patient is not my job.	Providing respectful care is less important than providing effective clinical care.	Reverse statement for a more pronounced moral hierarchy.	It's more important to provide effective clinical care than it is to provide respectful care.
12	When medicine is given, it is important that I explain well what it does for the patient and how it helps them.	No change	Low variability but no indication of change needed due to CI, possibly wrong construct to measure.	When medications are given, it is important that I explain well to patients how they work and how it will benefit them.
13	I think it is important to spend enough time with each patient, even if I have other job demands (low response variability).	No change	Low variability, more specificity about time spent.	It is important to spend time putting patients at ease, even on a busy day.
14	My job is to diagnose and treat parents not to be a health educator.	My job is to diagnose and treat patients not to be a health educator for each patient.	No change needed.	My job is to diagnose and treat patients, not to be a health educator for each patient.
15	Engaging patients in discussions leads to better health outcomes than just telling them what is best for them (low response variability).	No change	Low variability but no indication of change needed due to CI, possibly wrong construct to measure.	Engaging patients in discussions leads to better health outcomes than just telling them what is best for them.
Providers' attitudes on gender norms
16	A man should have the final word about decisions in his home.	A man should have the final say on decisions made in his home.	No change needed	A man should have the final say on decisions made in his home.
17	It is the man who takes the initiative to have sex with his wife.	Dropped	Dropped	Dropped
18	A woman's most important role is to take care of her home and cook for her family.	A woman's most important role is to take care of her home and cook for her family.	Align with GEM wording	A woman's most important role is to take care of her home and her family.
19	If a woman has a good idea, her husband should listen even if he disagrees (low response variability).	No change	Low variability	A woman must obey her husband in everything
20	Men and women should decide together about how many children to have (low response variability).	No change	Low variability Change to another GEM statement	It is important for men to be present in their children's life, even if he isn't with their mother anymore.
21	A man is expected to discipline his women.	No change	Change to another GEM statement	Sometimes a man must put his woman in her place.
22	Men should help take care of the children in the household (low response variability).	No change	No variability More specificity	A woman is the only one responsible for changing diapers, bathing and feeding her children.
23	There is never a good reason for a man to beat his wife.	No change	No change needed	There is never a good reason for a man to beat his wife.

Abbreviations: CI, confidence interval; GEM, Gender Equitable Men scale; HCP, health care provider.