Rationale and design of a complex intervention measuring the impact and processes of social accountability applied to contraceptive programming: CaPSAI Project

Abstract

Background: There are numerous barriers leading to a high unmet need for family planning and contraceptives (FP/C). These include limited knowledge and information, poor access to quality services, structural inefficiencies in service provision and inadequately trained and supervised health professionals. Recently, social accountability programs have shown promising results in addressing barriers to accessing sexual and reproductive health services. As a highly complex participatory process with multiple and interrelated components, steps and actors, studying social accountability poses methodological challenges. The Community and Provider driven Social Accountability Intervention (CaPSAI) Project study protocol was developed to measure the impact of a social accountability process on contraceptive uptake and use and to understand the mechanisms and contextual factors that influence and generate these effects (with emphasis on health services actors and community members). Methods: CaPSAI Project is implementing a social accountability intervention where service users and providers assess the quality of local FP/C services and jointly identify ways to improve the delivery and quality of such services. In the project, a quasi-experimental study utilizing an interrupted time series design with a control group is conducted in eight intervention and eight control facilities in each study country, which are Ghana and Tanzania. A cross-sectional survey of service users and health care providers is used to measure social accountability outcomes, and a cohort of women who are new users of FP/C is followed up after the completion of the intervention to measure contraceptive use and continuation. The process evaluation utilizes a range of methods and data sources to enable a fuller description of how the findings were produced. Conclusion: This complex study design could provide researchers and implementers with the means to better measure and understand the mechanisms and contextual factors that influence social accountability processes in reproductive health, adding important findings to the evidence base.

Adaptation and validation of social accountability measures in the context of contraceptive services in Ghana and Tanzania

“…The development of these measures is part of a more extensive complex intervention study, Community and Provider Social Accountability Intervention (CaPSAI), undertaken in Tanzania and Ghana [ 36 ]. These countries were selected based on the following criteria: (1) existence of a national civil society organization (CSO) partner with experience in social accountability, (2) low modern contraceptive prevalence rate, (3) availability of contraceptive services at the point of contact where cost is not a barrier to access, (4) an enabling environment in terms of the potential for the health system to respond to the social accountability, and (5) the existence of formal structures linking the community with the health system (e.g.…”

“…The study took place in Mbeya City and Chunya districts in Tanzania, and Abura-Asebu-Kwamankese, Komenda-Edna-Eguafo-Abirem, and Mfantsiman districts in Ghana. The sites were selected based on (1) the provision of contraceptive services; (2) availability of the following methods: a barrier method, a short and long-acting method, emergency contraception, and at least referral for permanent methods in districts; and (3) no social accountability interventions in FP/C currently underway [ 36 ] Table 1…”

“…The theory of change drew on existing empirical and theoretical work on social accountability more broadly and specifically related to sexual and reproductive health (see [ 7 , 8 , 36 ]). This informed the dimensions in the measure.…”

“…1 , details the inputs of the social accountability process (across the top of the diagram), how these correspond to the cumulative intermediate outcomes at three levels: (1) service users, (2) social networks and (3) service providers, which in turn, effect intended reforms in the quality of care that contribute to contraceptive choice, including increased uptake and use of modern contraceptive methods. As detailed in elsewhere, social accountability engages community members and health services actors in dialogues to identify shared challenges and develop action plans that can lead to improvements in service quality in the health system and in at the individual level, the service user or potential user knowledge and engagement with the health system, both in terms of their own health seeking behaviour and their participation in dialogues with authorities [ 36 ].

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“…Though few validated measures aim to capture these variables, a notable exception is CARE’s Women’s Voice tool that provides an important starting point for researchers in this area [ 34 ]. As part of a more extensive complex intervention study [ 36 ], we adapted and validated measures of service users’ attitudes and behaviors in a social accountability process to improve family planning services. In this paper, we describe the process of adapting the measures and assessing their validity and reliability in Ghana and Tanzania.…”