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Article Excerpt
Each year, 3.1 million unintended pregnancies occur in the United States, (1) potentially leading to negative consequences for women, families and society. (2) High-quality family planning services are essential for preventing unintended pregnancies, since large numbers of women obtain contraceptive methods through these services. Family planning services also commonly provide routine gynecologic care, testing and treatment for STDs, and information and counseling. Evidence of the importance of these services to American women is the prevalence of their use: Each year, 73% of women of reproductive age (15-44) use a family planning or related medical service. (3)
Different definitions of high-quality family planning service have been proposed; (4-6) an element common to most is that services should be responsive to the values, needs and preferences of clients. When services are client-centered, they are best able to meet clients' needs, because they provide clients with the desired information and supplies, and treat clients appropriately (4,7,8) By contrast, when services are not client-centered, clients may not get what they want and may not feel they were treated appropriately, which may influence their likelihood of returning to the provider, their ability to practice contraception effectively and even their reproductive health outcomes.
To ensure that family planning services are responsive to clients, it is important to understand clients' perspectives on care and, in particular, their views on what constitutes good or poor service. Existing research on clients' perceptions of U.S. family planning services has several limitations. First, much of it is dated. (9) Second, most studies of clients' perceptions have used surveys, (9) whose results may be affected by positive response and social desirability biases. (10-12) Also, surveys tend to reflect researchers' or providers' concerns, and may fail to fully capture clients' experiences or values. Complementary research using qualitative methods may provide better understanding of clients' perceptions of and experiences with health care. (8,10,13) Open-ended questions allow participants to describe their experiences, perspectives and behaviors in their own words, without fitting their responses into predetermined categories. As a result, qualitative studies are more participant-driven than surveys, are more open to emergent concepts and can lead to a deeper understanding of client experiences. (10,14)
A third limitation of existing research is that it has paid little attention to differences in women's experiences by race, ethnicity or language group. (9) Given current policy interest in addressing racial and ethnic disparities in health care, and the large body of research documenting disparities in various types of health services, (15) research into disparities in family planning care is a priority.
To address these limitations, we carried out a qualitative study to learn more about women's perceptions of and experiences with family planning services. Our objectives were to learn what service experiences clients consider positive or negative; to better understand clients' values and preferences regarding services; and to compare the experiences with care, and values surrounding care, of clients from four racial, ethnic and language groups.
METHODS
Study Design
Between January and April 2007, we conducted semi-structured in-depth interviews with 40 women recruited from the waiting rooms of two Title X-funded family planning clinics in the San Francisco Bay Area. Two female interviewers visited the clinics on different days of the week at different hours--including evening and weekend hours--and approached as many women as possible who were seeking care or who were accompanying others to assess eligibility and interest in participating in the study. To be eligible, women had to be black, white, Latina or a combination of these backgrounds, be aged 18-35 * and report at least two visits to a health provider for family planning services in the previous 10 years. ([dagger]) The response rate was not formally tracked, but women who declined to participate generally reported being too busy to stay for an interview; although we do not think the women in our sample were systematically different from the clinics' overall clientele, they may have been less busy and more open to participating in the study than the average client.
Latina participants were grouped as English- or Spanish-speaking, depending on their language of choice for the interview. Because one study objective was to compare the experiences of women in four racial, ethnic and language groups, we used a stratified quota sampling design, and set as a minimum recruitment goal eight participants per comparison group.
All interviews were carried out at the clinics in private rooms, except one, which the woman requested be carried out at her home. Most interviews took place immediately following women's appointments or, for women who were accompanying others, while they waited, but several were scheduled for a later date that was more convenient for the woman. The interviews lasted 30 minutes, on average, and were audiotaped if women consented. Six women opted out of taping; in these cases, written notes were taken. Participants received a $10 gift card to a local store. The study protocol was approved by the institutional review board of the Johns Hopkins Bloomberg School of Public Health.
The interview guide included 10 questions on women's lifetime experiences with family planning care and seven questions on their social and demographic characteristics (age, marital status, parity, education, country of birth, age at immigration and language preference among Latinas). The care questions were open-ended and asked women to describe the experiences they considered positive or negative and their views on ideal family planning care. Examples of questions include "Can you tell me about the best experiences you have had getting family planning care?" "Can you tell me now about some bad experiences you have had getting family planning care?" and "Can you describe for me what in your opinion would be an ideal family planning visit?"
Analysis
All taped interviews were transcribed, and the transcripts were double-checked for accuracy. The transcripts and interview notes were coded by the first author using Atlas-ti software. Our code list included codes based on concepts from the family planning literature that were evident in...
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