Description of study population: Most women were 25-29 year old (38.4%), with 30.5% being 18-24, 18.5% being 30-34 and 12.5% over 35 years (Table 1). Most women were illiterate or had none or primary school (40.1%), 19.3% had post-primary/ vocational/ secondary school, 33.1% college or above and 7.5% were still in school. Most were homemakers (93.8%). Most were other backwards caste (64.5%) or Scheduled caste/Scheduled tribe (21.8%) and were Hindu (81.8%). Just under half wanted more children (46.7%). There were significant differences between intervention and control groups, with the intervention group being slightly older, less educated, more other backwards caste/less general caste, more Muslim, having more sons and not desiring additional children.
Table 1: Demographics of the control and intervention survey participants (family planning clients), N, %.
|
Intervention
|
Control
|
Total
|
|
No.
|
%
|
No.
|
%
|
No.
|
%
|
Age group*
|
18- 24
|
154
|
28.4
|
177
|
32.7
|
331
|
30.5
|
25-29
|
189
|
34.9
|
227
|
41.9
|
416
|
38.4
|
30-34
|
102
|
18.8
|
99
|
18.3
|
201
|
18.5
|
35 and over
|
97
|
17.9
|
39
|
7.2
|
136
|
12.5
|
Education*
|
Illiterate/No school/Primary
|
236
|
43.5
|
199
|
36.7
|
435
|
40.1
|
Post-primary/vocational/Secondary
|
88
|
16.2
|
121
|
22.3
|
209
|
19.3
|
College or above
|
171
|
31.5
|
188
|
34.7
|
359
|
33.1
|
still in school
|
47
|
8.7
|
34
|
6.3
|
81
|
7.5
|
Occupation
|
Working
|
29
|
5.4
|
38
|
7
|
67
|
6.2
|
Homemaker
|
513
|
94.6
|
504
|
93
|
1,017.00
|
93.8
|
Caste group*
|
SC/ST
|
99
|
18.3
|
137
|
25.3
|
236
|
21.8
|
Other Backwards Castes
|
381
|
70.3
|
317
|
58.6
|
698
|
64.5
|
General
|
62
|
11.4
|
87
|
16.1
|
149
|
13.8
|
What is your religion*
|
Hindu
|
388
|
71.6
|
498
|
92.1
|
886
|
81.8
|
Muslim
|
154
|
28.4
|
43
|
7.9
|
197
|
18.2
|
Desire More Children*
|
No
|
310
|
58.5
|
257
|
48.2
|
567
|
53.3
|
Yes
|
220
|
41.5
|
276
|
51.8
|
496
|
46.7
|
*significant at the p<0.05 level difference between control and intervention
Quantitative evaluation findings from the survey with clients
The overall PCC score was not significantly different between the intervention and control groups, with a mean of about 29.3 (range from 0-43) (Table 2). Women in the control arm in general rated individual PCFP items slightly lower, although this difference was only significant for 4 items: the ASHA introducing herself, showing respect, feeling the ASHA wanted the best for her and being allowed a person of her choice to stay during the visit.
Table 2: Differences between women who saw intervention and control ASHAs in percent who report each person-centered care items, percentages shown unless otherwise stated
|
Intervention, percent of women reporting the two highest responses#
|
Control, percent of women reporting the two highest responses#
|
|
N
|
%
|
N
|
%
|
Total
|
536
|
100
|
541
|
100
|
PCC score (mean, IQR)
|
29.30
|
(28,36)
|
29.19
|
(27,35)
|
ASHA introduced herself when ASHA came (p=0.0000)
|
517
|
96.5
|
470
|
86.9
|
ASHA treated her with respect (p=0.0000)
|
520
|
97
|
481
|
88.9
|
ASHA wanted the best for her (p=0.0464)
|
468
|
87.3
|
449
|
83
|
Given enough information about her care in order to feel like she understood what was happening
|
423
|
78.9
|
420
|
77.6
|
ASHA involved her in decisions
|
410
|
76.5
|
409
|
75.6
|
ASHA clearly explained things
|
436
|
81.3
|
442
|
81.7
|
ASHA answered in a way that she could understand when she had questions
|
450
|
84
|
450
|
83.2
|
ASHA supported her anxieties and fears about family planning procedure or method choice
|
380
|
70.9
|
398
|
73.6
|
Felt she could ask the ASHA any questions they had
|
464
|
86.6
|
451
|
83.4
|
Felt she was allowed to have someone she wanted to stay with her during the visit (p=0.0366)
|
390
|
72.8
|
362
|
66.9
|
Felt the ASHA was available when she want to speak to the ASHA, had questions, or needed support
|
442
|
82.5
|
434
|
80.2
|
Felt the ASHA took the best care of her
|
400
|
74.6
|
415
|
76.7
|
Felt the ASHA cared about her as a person
|
447
|
83.4
|
454
|
83.9
|
Had complete trust in the ASHA with regards to her care
|
442
|
82.5
|
433
|
80
|
***p<0.000, **p<0.01, *p<0.05
#Two highest = “most of the time” or “all of the time” compared to “none of the time” or “some of the time”,
The majority of women reported that their ASHA was involved exactly the right amount in their family planning method choice (72.9%), with 16% stating they wished she was involved less and 11% that she was involved more (Table 3). Few differences emerged between the intervention and control. About 30% of women overall said that their ASHA had no preference or a slight preference, and only 10.6% that she had an extremely strong preference. It appears that women in the intervention group reported slightly higher levels of preference than women in the control group.
Table 3: Distribution of responses to other two quality measures by intervention and control groups, N(%), column percentages
|
Intervention
|
Control
|
Total
|
|
No.
|
%
|
No.
|
%
|
No.
|
%
|
How do you feel about how involved your ASHA was with helping you choose a family planning method?
|
I wish my ASHA had been less involved
|
39
|
15.4
|
40
|
16.5
|
79
|
16
|
My ASHA was involved exactly the right amount
|
183
|
72.3
|
178
|
73.6
|
361
|
72.9
|
I wish my ASHA had been more involved
|
31
|
12.3
|
24
|
9.9
|
55
|
11.1
|
Did your ASHA have a preference for what family planning method you should use?
|
No preference
|
108
|
20
|
129
|
23.8
|
237
|
21.9
|
Slight preference
|
47
|
8.7
|
65
|
12
|
112
|
10.4
|
Moderate preference
|
91
|
16.8
|
120
|
22.2
|
211
|
19.5
|
Strong preference
|
232
|
42.9
|
174
|
32.2
|
406
|
37.5
|
Extremely strong preference
|
63
|
11.6
|
52
|
9.6
|
115
|
10.6
|
Don't know
|
0
|
0
|
1
|
0.2
|
1
|
0.1
|
Table 4 shows that women who had higher person-centered family planning scores (rated their interaction as better) for their interaction with the ASHA had increased odds of taking up a family planning method (OR=1.04***, p=0.000). Receiving care from an intervention ASHA was not associated with PCFP scores. Receiving care from an intervention ASHA was also not associated with saying that the ASHA was involved the “right amount.” However, receiving care from an intervention ASHA was associated with increased odds of a woman saying that the ASHA had a “strong” or “extremely strong” preference for what method she chose (OR=1.861,p=0.000). Age was significantly associated with outcomes in all models, other control variables were not consistently associated.
Table 4: Association between PCFP score and current family planning use (at three month follow up), and the impact of the intervention on person-centered related outcomes
|
Currently using family planning (at three month follow up)
(Odds ratio, standard errors)
|
PCFP
Score
(coefficient, standard errors)
|
ASHA had a strong or extremely strong preference about Method
(Odds ratio, standard errors).
|
ASHA was Involved the right amount
(Odds ratio, standard errors).
|
PCFP score
|
1.041***
(0.00748)
|
|
|
|
Intervention
|
|
0.876
(0.528)
|
1.861***
(0.249)
|
1.098
(0.152)
|
Age (compared to 18-24)
|
25-29
|
0.911
(0.143)
|
0.249**
(0.176)
|
1.234
(0.192)
|
0.900
(0.145)
|
30-34
|
1.093
(0.211)
|
0.163**
(0.142)
|
1.146
(0.219)
|
0.912
(0.180)
|
Over 35
|
0.468***
(0.111)
|
0.0299***
(0.0312)
|
0.466***
(0.110)
|
0.484***
(0.126)
|
Education (compared to illiterate/none/primary
|
Secondary/post-secondary
|
1.148
(0.204)
|
0.452
(0.361)
|
1.287
(0.227)
|
0.702*
(0.129)
|
College
|
0.998
(0.153)
|
0.0457***
(0.0312)
|
1.246
(0.189)
|
0.601***
(0.0964)
|
Still in school
|
1.001
(0.255)
|
4.087
(4.712)
|
1.235
(0.313)
|
0.975
(0.251)
|
Occupation (homemaker compared to working)
|
0.648
(0.176)
|
3.062
(3.693)
|
1.303
(0.354)
|
1.103
(0.326)
|
Caste (compared to Scheduled Caste/tribe)
|
Other Backwards Caste
|
1.178
(0.192)
|
3.356*
(2.465)
|
0.898
(0.146)
|
1.298
(0.224)
|
General
|
1.154
(0.258)
|
4.657
(4.667)
|
0.981
(0.217)
|
1.437
(0.337)
|
Religion (Muslim vs Hindu)
|
0.907
(0.159)
|
0.460
(0.370)
|
1.017
(0.180)
|
0.896
(0.167)
|
Desire More Children
|
1.123
(0.153)
|
0.196***
(0.120)
|
0.945
(0.127)
|
1.027
(0.144)
|
Constant
|
0.479*
(0.210)
|
4.476e+13***
(7.532e+13)
|
0.501*
(0.189)
|
0.582
(0.235)
|
Observations
|
1,056
|
1,056
|
1,056
|
1,056
|
R-squared
|
|
0.048
|
|
|
*** p<0.01, ** p<0.05, * p<0.1
ASHA’s perspectives on the PCFP training from the qualitative interviews
The qualitative sample (N=20) included 11 intervention ASHAs who had participated in the PCFP training and nine control ASHAs who did not. Respondent ages ranged from 28 to 42 years (mean: 34.8). One half of the sample had completed lower secondary school up to grade ten and the other half had completed upper secondary school up to grade 12.
Intervention ASHAs already had deeply engrained PCFP values, including respect, support, communication, and maintaining privacy. Despite this, the intervention ASHAs still felt that there was value in the PCFP training, and described how it changed their perspective or practice related to various domains of PCFP.
One ASHA noted that the training changed the way she thought about her role as an ASHA. Afterwards, the ASHA not only started viewing herself as an agent of change, but also recognized that using disrespectful treatment can impact a beneficiary’s choice to pursue family planning care. In her interview she shared what she and some of her fellow ASHAs garnered from the training: “We have to first change our behavior (before) we can change others’. This is what we found different. Suppose if someone (behaved) badly with me, if (I) would have also done the same, then they wouldn’t have called us back.” (Respondent 4, Intervention)
Communication was another main topic in the PCFP training. One respondent shared how the PCFP training changed her perspective on respectful communication:
I would get angry before, not now. I tell them, “Don’t get anything done, at least you can talk with me. If you are busy now, I shall come after an hour and talk to you.” When I talk to them softly, they understand me. And if she is busy, she will not listen to me. I should talk with her later. Then she will think about what I said. I should talk with the beneficiary according to her convenience. (Respondent 16, Intervention)
Respondents directly and indirectly spoke about elements of effective communication throughout their interviews. ASHAs noted that when providing care, it was important to communicate in a way that beneficiaries will understand. As one ASHA shared about applying clear communication to family planning counseling: “We haVe to explain all thing(s) about family planning, in their language. If we explain (to) them in theoretical language, then they will understand nothing.” (Respondent 5, Intervention)
In the PCFP training, ASHAs learned about respecting autonomy when meeting with beneficiaries. One intervention respondent reflected on PCFP teachings: “We should listen to them [beneficiaries]. We should not impose our choice on them. We should not talk with them in harsh manner; not be angry with them. I should not say, ‘Get Multiload inserted.’ This is imposing. I should ask her, “What is (your) choice?” (Respondent 1) A second respondent reiterated this and went on to specify how she applies PCFP components like respect and autonomy when interacting with beneficiaries: “Suppose if they're not ready to use methods like sterilization or IUCD for whatever maybe the reason. [I] have to try to understand their problem. I cannot force them to use such methods. We cannot pressure them.” (Respondent 5, Intervention)
One intervention respondent reflected on what she learned about transparency at the PCFP training: “I got to learn that we should tell both good and bad things to the beneficiaries. We should tell all the products of family planning and let her choose. We cannot force them.” (Respondent 13, Intervention)
Another ASHA reflected on applying the PCFP dimension ‘privacy’ in the home setting to help create space for beneficiary-led decision-making. She found confidentiality and privacy to the most important aspects of PCFP training:
Most important of all was keeping everything confidential. Suppose we have visited…a (beneficiary) and everyone in her family is sitting nearby. Suppose I need to ask her about the Multiload, however other family members don’t know about her thinking of getting Multiload done. Therefore, confidentiality becomes important here, so we will take her aside and discuss in private. (Respondent 2, Intervention)
Another ASHA talked about how the PCFP training directly impacted her privacy practices and changed her strategy for speaking with women about family planning: “We have to talk with her [the beneficiary] separately so that no one knows about it – secrecy. Before (the PCFP training) we started talking (with) others, so even if she wanted to take benefit, she could not.” (Respondent 1, Intervention)