The study of client-provider interactions: a review of methodological issues

Abstract

In recent years, increased focus on the quality of family planning and other reproductive health services has led to a better understanding of women's reproductive health needs and has drawn attention to program-client interactions as a critical and neglected dimension of program effort. In this article, the relevant methods and experience related to studying client-provider interactions within family planning programs in southern countries are reviewed. The policy relevance of this work is highlighted first by stressing the operational usefulness of examining what happens when people engage with service-delivery systems that offer family planning or reproductive health services. Subsequently, the content areas encompassed by program-client interactions are clarified by identifying manifest and latent dimensions and by distinguishing the variables that define these interactions from variables related to their determinants and consequences. Finally, a critical review of existing methods is presented, with examples of research and a discussion of ethical issues.

PIP: An increasing focus on quality of health care has led to an understanding that program-client interface is a critical area in the provision of women's reproductive health care. A review is provided, therefore, of relevant methods and experience related to the study of client-provider interactions within family planning (FP) programs in southern countries. Program-client interface is studied because of the proximate, operational, and determinant roles it plays in the effectiveness of FP efforts. In order to describe and interpret the nature of this interface, manifest and latent dimensions of the interaction should be considered. Manifest dimensions include qualitative indicators (service coverage, frequency, and duration); quality-of-care elements such as choice, technical aspects, information content, and interpersonal relations; and variables which measure the nature of the services provided. Latent dimensions include fundamental differences in the status, power, and culture of participants. Important direct program determinants include provider characteristics, morale, supervision, work effort, resource availability, logistics, supplies, record keeping, costs, and service setting. Client population determinants are demand for fertility regulation, social and demographic characteristics, women's status, and health beliefs. A further distinction can be based on the consequences of the interaction such as contraceptive use, continuity of use, user satisfaction, and whether reproductive goals have been met. Both quantitative and qualitative research techniques should be applied to the study of client-provider interaction. The assessment strategy should also be relatively rapid with results validated by in-depth evaluation. The use of participatory approaches would also benefit this research. Such collaboration is emphasized by the organization-development literature, participatory action research, and feminist literature. Ways to study these interactions from the client perspective include 1) household surveys, 2) interviews with clients (exit and follow-up), and 3) other techniques such as focus-groups, intercept studies, Q-sort exercises, and ethnographic approaches. The perspectives and experiences of providers are revealed through surveys, in-depth interviews, focus-group discussions, reviews of hypothetical cases, and role-playing. Interactions can be observed using a structured observation guide or less structured approaches, audio-or videotape review, or the simulated client method. It is important not to overlook the ethical and strategic issues in this research. Ethical issues relate to communicating the intent of the research, safeguarding confidentiality, and assuring culturally appropriate interpretations. A strategic approach means that the research will be conducted with an awareness of the sensitive aspects of existing conditions.