Outreach Camps through MSI Clinical Outreach Teams (COT, Rajasthan… · Marie Stopes India 2012 Client Exit Interview Report Outreach Camps through MSI Clinical Outreach Teams (COT,

Marie Stopes India 2012 Client Exit Interview Report

Outreach Camps through MSI Clinical Outreach Teams (COT, Rajasthan) and MSI supported Government camps in Nagaur, Rajasthan

and Uttar Pradesh 28th December 2012

Percent of clients who are…

All Clients Govt Nagaur MSI COT Govt UP

Living Under

$1.25/day

Under Age

25

Adopters

Evidence to Action! Key recommendations from the data:

1. Inception of Youth Task Force. 2. Emphasis on method mix. 3. Innovative BCC and marketing strategies

to reach the unreached.

Exceed national FP sector by more than 10% points

Within 10% points (+/-) of national FP sector

Miss national FP sector by more than 10 % points

Comparison data not available

Facts at a glance:

•Youth:

--0% of clients under age 20

•Travel:

--Clients travelled 30 minutes on average to reach Govt Nagaur camps and MSI COT sites, and 40 minutes to reach Govt UP sites

•Follow-up:

--75% of clients report receiving follow-up instructions!

•Marketing:

-- 2.5% of clients report radio use and 25% report television use

--27% of clients reported using a mobile phone

Family Planning Behaviour:

--17% of total clients switched from a short-term family planning method to a long-term method

--24% of Govt Nagaur clients switched

--14% of MSI COT clients switched

--34% of Govt UP clients switched

41.4% 35.9% 39.2% 50.8%

13.2% 18% 13.5% 4.9%

80.3% 76.2% 83.4% 63.9%

13%

Under age 25

41%

Living under $1.25/day

Looking at National data comparisons for % living under $1.25/day (Graph 1), Overall 41% of the

clients availing services were living under $1.25/day. This is within 10% points of National FP data of

32.7%.

Graph 1: National data comparison for % living under $1.25/day

Similarly, 13% of all the clients were under age 25 population (Graph 2). This is again within 10%

points of National FP data of 10% clients at all the three camp types were within +10% points of

National FP sector (10%).

Graph 2: National data comparison for % under 25 years

Exit Interview Report 2012 Marie Stopes International

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80%

Percentage of Adopters

National data for comparison of adopters is not available. However, 80% of all the clients were

adopters (Graph 3).

Graph 3: % of Adopters

Background

Whilst our MIS data gives us some basic information about the clients we serve, the information we

collect does not give a detailed client profile and their satisfaction level with our services. During a

series of exit interviews we collected various socio-demographic data, details of what services our

clients were receiving that day, our clients’ satisfaction with different aspects of our services, and

information on media and mobile phone usage. MS India is specifically interested in understanding its

client profile including the age of clients and economic background. This would help the operations

team to develop strategies to reach the unreached eligible couples with unmet need. This is more

important now that MSI is focussing on generating CYPs that count i.e. High Impact CYP. Similarly

the level of satisfaction of clients with our services provide considerable feedback to the Clinical

Outreach Teams (COT) to improve their service delivery and provide counselling, privacy and follow-

up instructions in case the need be.

Section 1: Client Profile

FINDING 1: Females make up the majority of MS India clients with 98% of family planning clients

being females. Considering the age group of the clients, the weighted average was 13% clients in 20-


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24 years age group followed by majority (62%) in 25-29 years and 24% who were 30+. There were no

clients covered in the age group of 15-19 years. Looking at the trend from last year’s exit survey

findings, there are variations in the age group of clients. Though, this year as well there were no

clients in the age group of 15-19, however, the percentage of clients in the age group 20-24 years

went down from 28% in MSI COT in 2011 to around 14% this year. Almost 87 per cent of the clients in

COT camps were in the age group of 25+ as against 73% in 2011. There are significant variations in

the type of camps, as clients in UP are older than in Rajasthan. More than 60% of the clients in Govt

Nagaur camps and MSI COT camps were in the age group of 25-29 years as against 30% in Govt UP

Camps. In Govt UP Camps, majority of the clients (66%) fall in the 30+ age group. Similarly, only 5%

were in the age group of 20-24 years in these camps.

Almost 63% of the total clients (65% in Govt Nagaur, 63% in COT and 68% in Govt UP) had none/non

formal education. More than 40% of the clients were unemployed in both Govt Nagaur and COT

camps as against 80% in UP camps. Conversely, almost 47% were involved in agricultural activities

in both Govt Nagaur and COT camps whereas only 8% were doing any agricultural activities. This

difference could be due to difference in work pattern of females. In Rajasthan, women are involved in

agricultural activities as against the two MS India focus districts where females are generally involved

in only household chores. Interestingly, around 98% of all the clients already had two or more living

children before they decided to use family planning method from MSI. More than 90% of all the clients

in Rajasthan and 65% clients in UP already had either one or two living boys. This highlights the

preference for a male child before they decide to stop or space their pregnancy.

96% of MSI outreach service clients are Hindu in both the States followed by 4% Muslims. Looking at

caste composition, on an average, 48% of clients availing these services are from other backward

classes (OBCs), followed by 22% schedule tribes (STs) and 19% schedule caste (SCs). Indian caste

system is a system of social stratification and social restriction in which communities are grouped

under the four well known categories: Brahmins (priests), Kshatriyas (kings, warriors, law enforcers,

administrators), Vaishyas (traders, bankers), and Shudras (Artisans, labourers, agriculturists, cattle

raisers, craftsmen). The Government of India has officially documented castes and sub-castes. As per

Census 2011, Scheduled Castes, Scheduled Tribes and Other Backward Classes constitute 16%, 7%

and 32% of the total Indian population) respectively. National Family Health Surveys have highlighted

that these people are often the most underserved and in need of health services. The survey data

highlights that the MSI services reach a disproportionally high percentage of people from these casts,

proving that MSI is reaching the underserved population of the two States.

Table 1: Background characteristics of core service clients, by delivery channel


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SERVICE DELIVERY CHANNEL

Socio-demographic

characteristics

Weighted Average

N = 198

Govt Nagaur

N = 101

Outreach

N = 253

Govt UP

N= 122

Sex

Male 2% 3% 2% 0%

Female 98% 97% 98% 100%

Age

15-19 0% 0% 0% 0%

20-24 13.2% 18% 13.5% 4.9%

25-29 62.4% 64% 66.9% 29.5%

30+ 24.4% 18% 19.5% 65.6%

Relationship Status

Single/never

married

0% 0% 0% 0%

Married 100% 100% 100% 100%

Living together 0% 0% 0% 0%

Widowed/

Separated/divorced

0% 0% 0% 0%

Education level

none / non-formal

Some primary

63.1%

13.1%

65.3%

10.9%

62.5%

13.8%

68%

7.4%

completed primary 16.7% 13.9% 17.4% 14.8%

Some secondary

completed secondary / vocational or technical training

5.1%

1.0%

9.9%

0%

4.7%

1.2%

5.7%

1.6%

some tertiary or higher

1% 0% 0.4% 2.5%

Poverty

Less than $1.25 per day

(using the PPI)

41.4% 35.9% 39.2% 50.8%


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Below national poverty

line

23.8% 20.1% 22.4% 31.4%

Occupation

Unemployed 47% 47.5% 42.7% 78.7%

Agriculture 42.9% 46.5% 47% 8.2%

Unskilled manual 6.6% 4% 6.7% 5.7%

Skilled manual 1.5% 0% 2% 0%

Sales and

services

1% 2% 1.2% 1.6%

Clerical 0.5% 0% 0% 5.7%

Professional / technical

/ managerial

0.5% 0% 0.4% 0%

Student 0% 0% 0% 0%

Median time to reach

MSI provider

30 30 40

Service Utilisation

FINDING 2:

Around 96% of the female clients opted for female sterilization in Rajasthan irrespective of the service

provider. On the other hand, the method mix was different in Uttar Pradesh, where almost a similar

percentage opted for both female sterilization (52%) and IUD (48%). There was no client for male

sterilization in UP. In UP the reason for high percentage of IUD users can be attributed to less number

of surgeons at the facility level to perform sterilizations whereas govt staff nurse, ANM is more widely

available and trained in inserting IUD even at the sub centre level. There were variations among

clients who reported receiving FP counselling based on camp type. Around 64% of MSI COT camp

clients reported receiving counselling, followed by 52% of Govt Nagaur clients and 39% of Govt UP

clients. There have been variations in FP counselling from last year since in 2011, counselling was

more prominent at village level rather than at facility level. However, from 2012, on-site FP

counselling has been given a priority.


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96%

3% 1%

52%

96%

2% 2%

64%

51.6%

0%

48.4% 38.5%

Female Sterilization Male Sterilization IUD FP Counselling

Service Utilization

Govt Nagaur MSI COT Govt UP

Figure 1: Service utilisation of exit interview clients, according to type of service provider

Reaching the underserved

In order to assess if we are reaching the poorest segments of the population we compared the % of

family planning clients who live on less than $1.25 per day to the % of the national population living on

less than $1.25 a day (using World Bank data).

We also used educational status as a proxy for socio-economic status. We compared the % of our

family planning clients with less than a primary level of education to the % of all modern method users

in the country (using DHS data) with less than a primary level of education.

The young are often an underserved and high priority group for family planning. We compared the

percentage of our family planning clients that are under 25 years old with the percentage of all

modern method users in the country (using DHS data) that are under 25 years old.

Table 2: poverty and education level and age of MSI clients compared to national population

Poverty Indicator:

Weighted

Average

N = 198

Govt Nagaur

N = 101

MSI COT

N = 253

Govt UP

N= 122

National Data

Comparisons

% that live on less

than $1.25 a day

35.9% 39.2% 50.8% 32.7%


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% that have no

education or some

primary education

76.3% 76.2% 76.3% 75.4% 55%

% that are under 25

years old

13.2% 18% 13.5% 4.9% 10%

FINDING 3: Findings revealed that MS India program is at par with the National data of 33% that live

on less than $1.25 a day in Rajasthan. However, the country program is targeting more clients in this

category in UP. Looking at different types of camps, the program is covering 51% of poor clients in

govt UP camps as compared to 36% and 39% in govt Nagaur and MSI COT respectively. However,

this percentage has declined from 62% to 39% in MSI COT camp clients. Further running a

significance test (t-test) at 90% confidence interval reveals that there is statistically significant

difference between Govt Nagaur and Govt UP as well as MSI COT and Govt UP clients coverage.

Looking at the % of clients who have BPL card, overall 32% clients have BPL card. Around 19%

clients in Govt Nagaur, 36% in MSI COT and 14% in Govt UP camps have BPL card.

Similarly, looking at the percentage of clients that have no education or some primary education, the

project is successfully serving the uneducated population (76% as against 55% of national population).

This percentage has gone up by 8 percentage points from last year. Likewise, the program’s reach to

young people under 25 years of age is also comparable to the national population (13% compared to

10% of national population). However, this percentage has come down by 10 percentage points since

last year.

Family planning adopters and switchers

FINDING 4:

Looking at the weighted average, almost 80% of the clients that visited the camps were not using any

family planning method in the previous 3 months; 5% were continuers of MSI services and 15% used

a method from another provider. Looking at different camp types Govt Nagaur had 76% adopters,

MSI COT had 83% and Govt UP witnessed 64% adopters. A t-test revealed statistically significant

difference in adopters between MSI COT and Govt UP camp clients. Again, 1%, 4% and 14% of the

clients visiting these camps respectively were MSI continuers of service i.e. they were using a modern

method in the previous 3 months from MSI. Likewise, 23% of Govt Nagaur clients, 13% of COT

clients and 22% of Govt UP clients reported using a modern method in the previous 3 months but

from another provider. Looking at the clients who moved from short term method to LAPM, overall


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17% have switched their FP method with a camp wise breakup of 24% of Govt Nagaur clients, 14%

COT clients and 34% Govt UP clients. Again statistical significant difference was observed between

percentage of switchers in MSI COT and Govt UP camp clients.

Another important indicator reflecting the extent to which we are reaching the underserved is whether

we are providing family planning to people that were not already using it. The findings reveal that

almost 87% of the total clients have never ever used any family planning method before coming to

MSI services. It is important to reach people that were not already using modern family planning, in

order to expand contraceptive prevalence and grow the family planning market. Reaching these types

of clients will have a greater impact than serving clients that were already using family planning

anyway.

Table 3: family planning adopters and continuers

Weighted Average

N1 = 198

Govt Nagaur

N = 101

MSI COT

N = 253

Govt UP

N= 122

% of family planning

adopters1

80.3 % 76.2% 83.4% 63.9%


continuers2

4.5% 1% 4% 13.9%


clients that did use a

modern method in the

previous 3 months that

was provided to them by

another provider

15.2% 22.8% 12.6% 22.1%

1 Family planning adopters are those clients that did not use a modern family planning method in the 3 months

prior to receiving the MSI service

2 Family planning continuers are clients that did use a modern method in the previous 3 months that was

provided to them by MSI (Continuers)


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Table 4: short term method to long-term method switchers

Weighted Average

N = 198

Govt Nagaur

N = 101

MSI COT

N = 253

Govt UP

N= 122


clients that switched from

a short term method of

family planning to a long

term method

17.2% 23.8% 13.8% 34.4%

Data triangulation using MIS Data

MS India program has taken the three sub-groups under Outreach camps as separate camps namely

Govt Nagaur, MSI COT and Govt UP. Comparing the service use of these three types of camps vis-à-

vis annual MIS data and Exit Interview data, quite interesting findings emerged. Female sterilization

remained the preferred choice as well during the exit survey period. However, further looking at the

preferences within MIS and exit survey data revealed that clients had a higher preference for female

sterilization during the period of exit survey (Nov-Dec) as compared to the year (96%vs81% in MSI

COT and 52%vs37% in Govt UP). Conversely, preference for IUD had gone down during the exit

survey period as against the rest of the year (2%vs17% in MSI COT and 48%vs63% in Govt UP). The

reason could be the ‘seasonality’ associated with sterilization. It is a common belief among the

community that surgeries should be done on the onset of winters for easy healing and early recovery.

Diwali (Indian festival) is marked as the beginning of winters and therefore sterilization cases rise post

Diwali. The EI survey was done post Diwali. IUD is preferred during the ‘off season’. However, this

trend was not witnessed in Govt Nagaur camps.

MIS and Exit Interview Data of Govt UP Camps

Govt UP Camps

MIS data on number of SERVICES

MIS data on number of

CLIENTS EXIT INTERVIEW

SAMPLE SIZE

MIS data on percentage of clients

EXIT INTERVIEW

data on percentage

of clients

Female sterilisation

1304 1304 63 37.2 51.6

Male sterilisation

3 3 0 0.08 0

Intra-uterine system or device 2195 2195 59 62.7 48.3


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TOTAL NUMBER OF CLIENTS 3502 3502 122 100 100

MIS and Exit Interview Data of MSI COT Camps

MSI COT




SAMPLE SIZE

MIS data on percentage of

clients

EXIT INTERVIEW

data on percentage of

clients

Female sterilisation 8228 8228 243 81.7 96.04

Male sterilisation

140 140 5 1.4 1.9



MIS and Exit Interview Data of Govt Nagaur Camps

Govt Nagaur




SAMPLE SIZE

MIS data on percentage of

clients

EXIT INTERVIEW

data on percentage of

clients

Female sterilisation 4032 4032 97 98.4 96.03

Male sterilisation 34 34 3 0.83 2.9




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Section 2: Client Satisfaction and Quality of Care

FINDING 6:

Four indicators were used to assess overall satisfaction rates. Namely:

1. % of respondents who would recommend the MSI facility to a friend

2. % of respondents who would return to the facility to use another service in future

3. % of respondents who were satisfied or very satisfied with their overall experience with the

MSI service provider

4. % of respondents whose experiences met or exceeded expectations

Additional questions probed into the clients’ views of all aspects of service delivery in terms of:

opening hours, cleanliness, waiting time, friendliness and respect at reception, friendliness and

respect from the health care provider, time with the health care provider, quality of advice and

information, and procedure.

Table 6: Overall satisfaction by service delivery channel

Weighted

Average

N = 198

Govt Nagaur

N = 101

MSI COT

N = 253

Govt UP

N= 122

Would recommend the MSI

facility to a friend

99.5% 96% 100% 100%

Would return for another

service in future

78.7% 85.1% 75.9% 93.4%

Satisfied or very satisfied with

their overall experience at an

MSI facility

66% 56.4% 64% 89.3%

The experiences met or

exceeded expectations

99.5% 98% 99.2% 100%


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Almost all the clients irrespective of the channel, expressed that they would recommend the MSI

facilities to a friend. Also, 79% of the clients would like to return to the facility for another service in the

future. Almost 66% of them were satisfied or very satisfied with their overall experience at the facility

with significant differences visible between Rajasthan clients (56-64%) and UP clients (89%). The %

of clients satisfied at MSI COT camps is almost similar as compared to last year (65%). However,

client satisfaction at the Govt Nagaur camps which are the MSI supported govt camps is

comparatively low. The reason could be government staff who is involved in conducting procedures

and not MSI staff. Likewise, almost all the clients highlighted that the experiences either met or

exceeded their expectations. It was interesting to see that all the clients who were either satisfied or

very satisfied with their experience would recommend MSI facility to their friends. This percentage has

gone up from 67% in 2011.

Quality of Care: Follow-up instructions

FINDING 7: Although the exit interview showed a drastic improvement in providing clear follow-up

instructions to clients yet there is further scope of improvement in this aspect. Further analysis shows

that more than 70% of Rajasthan clients (both Govt Nagaur and MSI COT) as against 95% of Govt

UP clients received clear instructions. Compared to the last year’s survey findings, the rate of follow-

up instructions has improved almost twofold from 37% to 70% for MSI COT clients.

Section 3: Marketing

Sources of information on MSI services

FINDING 8: The most common source of information continues to be the Community based

distributor/village health worker with more than 90% of the total clients reporting hearing about MSI

services from them. It was almost 95% in 2011. Interestingly, MSI Outreach i.e. demand generation

before the camp was an important source of information for the clients receiving services in UP govt

camps (71%). This was followed by a recommendation from someone who has already used the

service (5-9%); media (5-8%) and government provider (5%). Similar findings were reported during

the last year’s exit survey where community based distributor/village health worker were both the

most common as well as most influential source of information for MSI services.

The reason for such high rate is that these are the government workers who are incentivised to bring

the clients.


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95%

10%

5%

4.8%

5%

95.5%

6.4%

5.7%

7.7%

5.1%

90.5%

71.4%

4.8%

4.8%

9.5%

0% 20% 40% 60% 80% 100% 120%

CBDW

MSIO

Govt

Media

Friend

Sources of Information about MSI service

Govt UP

MSI COT

Govt Nagaur

89%

3% 2%

1% 4% 1%

Govt Nagaur

CBDW

MSIO

Govt

Media

Friend

Others

Figure 2: Common sources of information about MSI service reported by clients

Almost 98% of outreach clients were aware of the MSI provider as a result of some form of marketing

or BCC material. There were not much variations based on service delivery channel. Around 75% of

family planning outreach clients were adopters AND were aware of the MSI provider as a result of

marketing or BCC. Further break down by camps highlights 72% and 81% of the clients in Govt

Nagaur and MSI COT were adopters and aware of MSI as against 63% clients in Govt UP camps.

Figure 3a: (Govt Nagaur) Sources of information that most influenced the client to use the MSI service


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93%

2% 4% 1%

MSI COT

CBDW

MSIO

Govt

Friend

Figure 3b: (MSI COT) Sources of information that most influenced the client to use the MSI service

Figure 3c: (Govt

UP) Sources

of

information that most influenced the client to use the MSI service


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60%

38%

2%

Govt UP

CBDW

MSIO

Govt

CBDW continue to dominate as the source of information as was seen in the last exit survey findings.

Looking at the source of information that most influenced the clients to use MSI services, state

specific variations were quite evident. Although almost 90% clients in Rajasthan (both Govt Nagaur

and MSI COT) were influenced by Community based distributor/village health workers/ANM/AWW,

only 60% of UP clients considered them to be influential source. In UP govt camps, almost 40%

clients reported getting influenced by MSI outreach workers. The most common reason for this could

be attributed to the fact that in Rajasthan, MSI outreach workers and government field level

functionaries support each other in creating demand for FP services and are considered as ‘one’ by

the community. However, UP being a comparatively new MSI program, and FP not being a priority of

government field staff, both the field workers are often seen separately and therefore the community

can easily distinguish one from the other.

Communication channels

FINDING 9: According to the exit interview data the most common type of media used by clients was

TV, reported by almost a quarter of the clients. However, almost half of the clients (48%) do not use

any media. Only around 30% of our clients own a mobile phone, increased from 16% last year. This

indicates that SMS and other mobile phone based innovations may not work with our clients. The

extent to which clients used other means of communication is explored below.


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Table 7: Media types used in the past two weeks

Weighted Average Govt Nagaur MSI COT Govt UP

N = 198 N = 101 N = 253 N = 122

Newspaper 5.1% 4% 4.3% 7.4%

TV 24.7% 23.8% 25.7% 17.2%

Radio 2.5% 1% 2.4% 5.7%

Magazine 0.5% 1% 0.8% 1.6%

Internet 0% 0% 0% 0%

Any other media 0.5% 0% 0.4% 1.6%

Does not use media

48% 34.7% 48.2% 55.7%

Declines to answer 0% 0% 0% 0%

Client motivation to attend MSI services

Clients were asked about their main motivation for visiting MSI that day, Each client was asked to

choose one factor that was the most influential in their decision to attend the MSI service on that day.

FINDING 10: The majority of clients irrespective of type of camps attended MSI services because of

proximity of the facility. Though more than 70% of the clients both in govt Nagaur and MSI COT

reported proximity as the main reason, around 43% reported the same in govt UP camps. In UP,

clients could get an IUD even at the Sub centre level which is generally close to their village. This

might be the reason that proximity was not a selling point for UP clients. This was followed by good

reputation of the service provider where 20% of clients in govt Nagaur, 13% in MSI COT and around

30% in govt UP reported this factor. (see figures 4a-c). Around 10% and 16% of the clients in MSI

COT and govt UP respectively also mentioned that they knew the provider/staff. Low cost was also an

important indicator to avail MSI services for clients in govt UP camps (10%). This year’s findings also

show a similar trend as last year.


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76%

1%

20%

3%

Govt Nagaur

Nearby

Low Cost

Good Reputation

Knows provider/staff

72%

4%

13%

10%

1%

MSI COT

Nearby

Low Cost

Good Reputation


Services/medicines available

Figure 4a – (Govt Nagaur) Percent distribution of most important reason behind choosing the MSI

service provider

Figure 4b – (MSI COT)


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43%

10%

30%

16%

1%

Govt UP

Nearby

Low Cost

Good Reputation


Referred by someone

Figure 4c – (Govt UP)

Section 4: Putting Evidence to Action

Making recommendations for programme improvements using Exit

Interview data

Key piece of evidence #1: Findings highlight that the program needs to target the young population

since currently we are targeting only 13% of the under 25 year old population and no adolescents

under 20 years of age. The young population would have high unmet need for spacing or delaying the

first pregnancy.3

Action item #1: Inception of Youth Task Force. MS India understands the importance of and is

committed to providing safe and accessible sexual and reproductive health services to the youth. MS

India has already nominated one staff member as the focal person to interact with MSI London in

developing and designing youth centred activities.

3 Center for Reproductive Law & Policy. International Family Planning and Reproductive Health Programs:

When Will the U.S. Government Fulfill Its Commitment. New York: The Center, 2001.


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Who is responsible for this area: The point person nominated would be working in close support and

coordination with the field teams including District Coordinators, Block Coordinators and IPCs.

Current status of this action item: One point person has been nominated to take this initiative further

Key piece of evidence #2: Currently, female sterilization is the only preferred choice as compared to

male sterilization, IUD and other spacing methods. This is quite evident from the exit survey findings.

Also, counselling needs further strengthening at all the three types of camps as has been highlighted

in the findings.

Action item #2: Emphasis on method mix and counselling to understand the choices clients have.

Studies have shown that limited method choice is a problem in rural areas and is one of the causes of

increased unsafe abortion rate4. It is imperative that the field staff be sensitized and informed about

the need to promote method mix during their one to one meetings and group meetings.

Who is responsible for this area: Field teams would be responsible after they have been provided

necessary counselling and skill development trainings

Current status of this action item: Counselling trainings for the IPCs have been planned in the first

quarter of the year.

Key piece of evidence #3: Even though the clients reported that they would recommend the facility to

a friend, currently less than 10% of the clients consider ‘someone who has used the service’ as a

source of information.

Action item #3: Peer Approach to identify potential clients and innovative BCC and marketing

strategies to reach the unreached. Since majority of the clients have no or some primary education,

and do not use media, the program needs to utilize other IEC activities like mobile video vans, flip

books, interactive games, etc to communicate the benefit of family planning and informing them about

the nearest such facilities. Additionally, the program must also utilize the existing

4 WHO Fact sheet N°351 July 2012


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grassroot/community groups to engage in family planning discussions. This will be a captive audience

to discuss the family planning needs of the community and informing the group about MSI services.

Who is responsible for this area: Field staff and communication officers.

Current status of this action item: Communication officer would be briefed on the findings through

dissemination workshop and IEC activities would be designed depending upon the target group in the

1st quarter of 2013.

Next Steps

In our pursuit to benchmark as an evidence-based organisation, MS India utilizes Exit Interviews as

an important source to understand their clients better and make their association with us a pleasant

experience. The findings from this survey help us understand what clients value about our services

and how they wish to see us improve. RME team at MS India will take the lead to disseminate exit

survey findings at various levels to feed the findings into the program.

1. Presentation and Circulation of report with key findings and recommendations to the SMT

members for necessary action – The Exit Survey findings will be shared with the Senior

Management Team during the SMT meeting. The SMT would include Program Director;

Operations Directors; State Program Managers; Clinical Services Manager, NBD Manager

and Finance Manager. This would be a good platform for necessary discussion and way

forward to design actionable points.

2. Trainings and Capacity building programs would be designed:

a) Counseling trainings would be organized for the Inter-personal communicators to further

develop their counseling skills and better utilization of IEC material.

b) Capacity building of the field staff and medical staff to ensure the clients has a satisfied

experience with MSI services. This would include maintaining privacy, reducing waiting

time, cleanliness, friendliness of the staff, quality of advice and follow-up instructions.

3. Circulation of reports to external stakeholders – An exit survey brief would be shared with the

NBD Manager to be used as a hand-out for circulation to our existing and prospective partners.

4. Dissemination workshops with district teams including field staff – It is essential to share the

findings of any survey with the teams involved at the field level. Dissemination workshops

would be conducted at the zone level (Jaipur and Udaipur zone) and both the disctricts of UP


22

with the District Coordinators, Clinical Outreach Team members, Block Coordinators and Inter-

personal Communicators. These workshops would provide necessary platform to share survey

findings and draw out strategies suggested by field implementers to improve upon their

existing work.

5. Printed material in the form of posters would be displayed at all the district offices for reference.

Appendix 1: Methodology

Exit Interview dates and locations

Client Exit Survey was carried out for 2 weeks from 26 Nov to 10 December 2012 in two states of

India i.e. Rajasthan and Uttar Pradesh. In Rajasthan 10 operational districts i.e. Jaipur 1 & 2, Ajmer,

Alwar, Sikar, Udaipur, Chittorgarh, Rajsamand, Banswara and Nagaur and in Uttar Pradesh two

districts Bareilly & Badaun were included in the survey. Broadly this survey was carried out at two

types of outreach camps i.e. MSI Supported Government (MSI SG) Camps and MSI Clinical Outreach

Team (COT) Camps. Being a new operational state, COT camps have not been introduced in Uttar

Pradesh yet, so in this state the survey was conducted at MSI supported government camp sites only.

In Rajasthan only MSI COT camps have been covered except one district Nagaur where both type of

camps were incorporated in the survey.

Sampling

Three different samples were taken, one in UP and two different ones in Rajasthan, where MS India is

providing service delivery. In UP and Nagaur in Rajasthan, MS India provides demand generation and

administrative support only whereas in 10 districts of Rajasthan, Clinical Outreach Teams provide

complete service delivery. The camps are therefore mentioned as Govt Nagaur, MSI COT and Govt

UP throughout the report.

Sampling Design:

Rajasthan: Site details are given in the table below:

SITE DETAILS AND SAMPLE COVERED IN RAJASTHAN


23

S.No Date Day Site Block District

Sample Covered

1 26-11-2012 Monday Phc Mokampura Banswara

6

2 26-11-2012 Monday Gudhabhagwandas Nagaur Nagaur

8

3 27-11-2012 Tuseday Chc Badarel Talwara Banswara

11

4 27-11-2012 Tuesday RAJPURBADA RAJGARH ALWAR

7

5 27-11-2012 Tuesday Paota Govindarh Jaipur-I

6

6 27-11-2012 Tuesday phc bobas Dudu Jaipur-II

2

7 27-11-2012 Tuesday Thanwla Riya Nagaur

10

8 27-11-2012 Tuesday Borwad Makrana Nagaur

4

9 28-11-2012 Wednesday Ladnun Ladnun Nagaur

6

10 28-11-2012 Wednesday PHC-PARA KEKRI Ajmer

5

11 28-11-2012 Wednesday BHIWADI TIJARA ALWAR

13

12 28-11-2012 Wednesday Khandela CHC Khandela Sikar

2

13 28-11-2012 Wednesday ItawaBhopji Govindarh Jaipur-I

5

14 28-11-2012 Wednesday Chc phagi Phagi Jaipur-II

8

15 28-11-2012 Wednesday CHC SARADA SARADA Udaipur

6

16 28-11-2012 Wednesday Ren Merta Nagaur

3

17 28-11-2012 Wednesday Kuchaman city Kuchaman Nagaur

5

18 29-11-2012 Thursday PHC-TOTGARH JAWAJA Ajmer

2

19 29-11-2012 Tursday Kaanwat Phc Khandela Sikar

6

20 29-11-2012 Tursday Aandhi J.Ramgarh Jaipur-I

9

21 29-11-2012 Thursday Padukalan Riya Nagaur

8

22 29-11-2012 Thursday Kuchera Nagaur Nagaur

5

23 30-11-2012 Wednesday Chc Ganoda Ghatol Banswara 3

24 30-11-2012

Friday PHC-RAMGARH MASUDA Ajmer 3


24

25 30-11-2012

Friday CHC Rawatbhata Rawatbhata Chittor 6

26 30/11/2012

FRIDAY CHC DELWARA KHAMNOR Rajsamand 2

27 30/11/2012

Friday CHC JHADOL JHADOL Udaipur 3

28 30-11-2012

Friday MANDHAN SAHAJAHAPUR ALWAR 9

29 30-11-2012

Friday Ajeetgarh CHC Sri Madhpur Sikar 4

30 30-11-2012

Friday Jahota Amber Jaipur-I 6

31 30-11-2012

Friday Parbatsar Parbatsar Nagaur 11

32 02-12-2012 Sunday Koikasim CHC Harsoli Alwar 7

33 03-12-2012 Monday Tizara CHC Bhiwadi Alwar 4

34 04-12-2012 Tuesday Bhim Bhim Rajsamand 2

35 04-12-2012 Tuesday Jhadol Jhadol Udaipur 8

36 05-12-2012 Wednesday Sarada Sarada Udaipur 8

37 05-12-2012 Wednesday Phagi Phagi Jaipur 12

38

07-12-2012

Friday Jayal Jayal Nagaur 8

39

07-12-2012

Friday Riya Riya Nagaur 6

40

07-12-2012

Friday Choti Sarwan Banswara 18

41

07-12-2012

Friday Phalasiya Udaipur 3

42

07-12-2012

Friday Rawatbhata Chittorgarh 10

43

07-12-2012

Friday Bagawas virat nager Jaipur-I 5

44

08-12-2012

Saturday Manana Makrana Nagaur 2

45

08-12-2012

Saturday Timeda Bada Kushalagarh Banswara 7

46

08-12-2012

Saturday Gatweri Jamwaram garh Jaipur-I 5

47

08-12-2012

Saturday Kotda Girwa Udaipur 7

48

08-12-2012

Saturday Mandaphiya Bhadesar Chittorgarh 4

49

09-12-2012

Sunday Tarnau Jayal Nagaur 5

50

09-12-2012

Sunday Phc madawri Phagi Jaipur-II 5


25

51

10-12-2012

Monday Didwana Didwana Nagaur 7

52

10-12-2012

Monday Medtacity Medta Nagaur 7

53

10-12-2012

Monday Makrana Makrana Nagaur 7

54

10-12-2012

Monday Deh Jayal Nagaur 17

55

10-12-2012

Monday Pragpura virat nager Jaipur-I 6

Rajasthan, MSI Clinical Outreach Team Camps: Cluster sampling was used for selection of

outreach sites as the total number of facilities were more (>30) and it was not feasible to visit all the

facilities. To get a representative sample of sites from all the districts 30 sites were considered

sufficient to survey, as recommended in the globally standardised MSI Exit Interview (EI) Protocol.

Sample size of the respondents was kept at 160 (which was the minimum sample size recommended

in the EI Protocol) to keep it more balanced against practical considerations like budget, cost and time.

Rajasthan, MSI Supported Government Camps: A census of all sites was used to calculate the

sample for MSI supported government camps with minimum total sample of 106 respondents since

the sites were less than 30.

Uttar Pradesh, MSI Supported Government Camps: List of sites given below:

SITE DETAILS AND SAMPLE COVERED IN UTTAR PRADESH

Dates Camp District Blocks Venue

Sample Covered

1 26.11.2012 FP Camp

Badaun Wazirganj PHC Saidpur 6

2 26.11.2012 FP Camp

Barelly Damkhoda CHC Baheri 2

3 26.11.2012 FP Camp

Barelly Bhojipura PHC Bhojipura 4

4 26.11.2012 FP Camp

Barelly Majhgawan PHC Majhgawan

5

5 26/11/1900 IUCD Badaun Ujhani PHC Kacchala 3

6 27.11.2012 FP Camp

Barelly Kuandanda CHC Kuandanda 3

7 27.11.2012 FP Camp

Barelly Meerganj CHC Meerganj 9

8 27.11.2012 IUCD Barelly Bhamora CHC Bhamora 1

9 27.11.2012 Barelly Bithrichainpur SC Rithora 5

10 27/11/2012 FP Badaun Asafpur PHC Asafpur 12


26

Camp

11 27/11/2012 IUCD Badaun Usawan PHC Katara 11

12 29/11/2012 FP Camp

Bareilly Bithari Chainpur

PHC Bithari Chainpur

3

13 29/11/2012 FP Camp

Bareilly Dalelnagar PHC Nawabganj 4

14 29/11/2012 FP Camp

Bareilly Nawabganj PHC Nawabganj 4

15 29/11/2012 IUCD Camp

Bareilly Dumkhoda CHC Baheri 1

16 29/11/2012 IUCD Camp

Badaun Samrer PHC Samrer 5

17

30.11.2012

FP Camp

Bareilly Fatehganj W

PHC Fatehganj W 5

18 30.11.2012

FP Camp

Bareilly Bhamora

CHC Bhamora 3

19 30/11/2012

FP Camp

Badaun Mianoo PHC Mianoo

13

20 30/11/2012

FP Camp

Badaun Usawan PHC Mianoo

21

30/11/2012

IUCD Camp

Badaun Mianoo PHC Mianoo

22 30/11/2012

FP Camp

Badaun Bisauli CHC Bisauli 6

23

30/11/2012

FP Camp

Badaun

Binawer

District hospital, Badaun

4

24

30/11/2012

FP Camp

Badaun

QuaderChauk

District hospital, Badaun

25

30/11/2012

IUD Camp

Bareilly

Bhidri_Chainpur PHC Bhidri_Chainpur 3

26

01.12.2012 IUCD Camp Badaun Dataganj

Sub centre Deharpur 2

27

01.12.2012 IUCD Camp Bareilly Bhamora PHC Bhamora 1

28

01.12.2012 IUCD Camp Bareilly Bhojipura PHC Bhojipura 4

29

01.12.2012 IUCD Camp Bareilly Nawabganj CHC Nawabganj 3

A census of all sites was used to calculate the sample for MSI supported government camps in UP

with minimum total sample of 106 respondents since the sites were less than 30.


27

Sample Selection:

In order to select sites according to the type of camps, three below mentioned lists of camps and

dates were prepared:

(1) List for MSI SG camps of Nagaur district of Rajasthan mentioned as Govt Nagaur

(2) List for MSI COT camps (Rajasthan only) mentioned as MSI COT

(3) List for MSI supported government camps UP mentioned as Govt UP

These was based on total number of sites and dates of camps allotted by district health authorities

specifically for the months of November and December in which data collection took place. For UP

Govt camps and Rajasthan Govt camps, a census of all sites visited during the data collection period

was taken. Rajasthan COT camps, sites were selected randomly from this list using MSI’s

standardized exit interview sample selector tool.

Minimum stratified sample sizes for all samples were calculated with the following formula:

n=Z2 pq / d2

where

n = number of respondents required using simple random sample

Z=1.96 corresponding to a confidence level of 95%

p = expected coverage for key indicator

q = 1-p

d = required level of accuracy, i.e. maximum size of confidence intervals

The recommended standard minimum sample size provided figures with 95% confidence intervals of

not more than + / - 10%, using the following parameters:

p = 50% (for most conservative sample size estimate)

q = 1-p

d = 10%

This gives the following minimum sample size:

N = (1.962 x 0.5 x 0.5)/0.12 = 96

This was increased by 10% (to 106) to account for non-response.


28

The sample size was then inflated when using the cluster sampling approach. The inflation factor was

the design effect, def, of using a cluster sample. This was estimated from previous exit interview

surveys.

nc = n *def

The minimum sample size when using cluster sampling was:

nc = 96 * 1.5 = 144

This was increased by 10% (to 160) to account for non-response.

(See Table 1). A proportional number of clients were interviewed at each site. Every 3rd client in

UP, every 4th client in Rajasthan COT camps and every 5th client in Nagur Govt camps was

interviewed to ensure clients were selected throughout the day.

Table A1: Sample description


Total number of Sites in country

44 99 22

Total number of sites in sample

14 28 19

Total number of respondents in sample

101 253 122

Questionnaire:

The Exit Interview tool consisted of six sections covering Interview & site information, service use,

marketing, demographics, client satisfaction & feedback on quality and Poverty Index. Few additions

were made in the demographic and marketing section. Specific question on religion, caste, Below

Poverty Line (BPL) card (BPL families are issued a card which allow them to avail schemes launched

by the Government) and number of living boys were added under the demographic section. Additional

option of ‘Camp Announcement’ was added under questions M3 and M4; and option of ‘any

community meeting’ and ‘health specific community meeting’ was added under M5 question in

marketing section. Further, the tool was back translated in Hindi language to make it simple and

understandable for both the investigators and the clients.


29

The tool was pre tested with 30 non-sample respondents, who visited the camps before the actual

survey started and were representative of the total population. The clients were able to comprehend

the content of the questionnaire and no comments or remarks were made to improve or change the

tool.

Data quality

Steps taken to ensure that the data collected was of high quality include:

Use of the standard MSI tools

Using double data entry

Data cleaning techniques like missing data, syntax editing based on MS India requirement

One day training for interviewers to familiarize them with the questions and conducting the

survey.

Exposure visit followed by real setting mock sessions with the investigators to give them a

proper understanding of probing and skipping pattern.

Supervisory monitoring visits were conducted by M&E officers in both states every alternate

day and daily progress reports.

Limitations

There were a few limitations of the study:

1. The sample included clients who have received the services during the data collection period.

The probability of selection for clients who availed services during other months was zero.

2. There were a few camp cancellations by the government due to competing priorities. Sample

selector was re-run for those districts to get new sites.

3. Post procedure (especially in case of female sterilization), some respondents were not willing

to respond either due to physical weakness or their attendants were in a hurry to take them

back home after the procedure. This might have an impact on the quality of responses from

the clients.

4. The timing when the follow-up instructions are provided to the clients also has an impact on

the responses. For example, in some camps follow-up instructions are provided when the

clients are waiting for their procedure while in others it is provided when they are leaving the

facility after the procedure.


30

5. Investigators faced challenge in obtaining responses from a few respondents who came from

very remote villages and did not understand Hindi properly. Investigators sought support from

the clients’ attendants to seek responses from those clients.

6. Likert scale for satisfaction measurement is not a very effective tool to assess the clients’

satisfaction from the services. Clients’ interpretation of ‘very poor’ or ‘very good’ is subjective

and may differ between respondents.

Appendix 2: Service Statistics

Table A2: family planning methods used in the past 3 months, among family planning clients that

used a family planning method in the last 3 months

Govt Nagaur

N = 24

MSI COT

N = 51

Govt UP

N = 45

Female sterilisation 0% 2% 0%

Male sterilisation 0% 0% 0%

Intra-uterine system or device

0% 11.8% 4.4%

Injectable contraception

0% 0% 0%

Implants 0% 0% 0%

Contraceptive pills 33.3% 31.4% 51.1%

Male condoms 66.7% 35.3% 42.2%

Female condoms 0% 0% 0%

Lactational Amenorrhea Method

0% 0% 0%

Other modern method (diaphragm, foam tablets, spermicidal jelly, vaginal ring, contraceptive patches)

0% 0% 0%

Traditional or folk 0% 17.6% 0%


31

methods (withdrawal,

rhythm, abstinence)

Emergency

contraception

0% 0% 2.2%

Among the family planning clients who used a family planning method in the last 3 months, 12% and

4% of them in both MSI COT and govt UP respectively used IUD. However, contraceptive pills and

male condoms were the most commonly used methods among all. Around 30% clients in Rajasthan

and 50% in UP have used contraceptive pills. Conversely, almost 67%, 35% and 42% clients in Govt

Nagaur, MSI COT and Govt UP respectively used male condoms during the last 3 months. Traditional

or folk methods were only reported by 18% clients in MSI COT camps.

Table A3: source of family planning method received in previous 3 months


This facility 3.1% 20.3% 39.7%

Other MSI provider 0% 0% 0%

Other provider 90.6% 77% 57.4%

Don’t know 6.2% 2.7% 2.9%

As per table A3, majority of the clients who were using a family planning method received it from

some other provider. Around 40% of the clients in govt UP camps and 20% in MSI COT camps

reported using any method previously from the present facility itself. This highlights that clients do re-

visit our services either to get re-fill of their supplies or to change their choices or preferences.

Around 33% of family planning clients (30% in govt Nagaur, 37% in COT and 26% in govt UP)

reported that they would not have used family planning if the MSI provider they were served by had

not been there (Table A4).

Table A4: Use Family Planning if the MSI Provider did not exist

Govt Nagaur

N= 101

MSI COT

N= 253

Govt UP

N= 122


32

Will not use FP if this facility did not exist

29.7 37.2 26.2

Clients would have had to travel a median time of 67 min in Nagaur, 60 min in MSI COT and 90 min in

govt UP to reach another provider. As per Table A5, one major problem clients reported that they

would face if the MSI provider did not exist was that they would have to travel further (43% in Govt

Nagaur, 31% in MSI COT and 37% in Govt UP).

Table A5: problems that clients report they would face if the MSI provider did not exist

Govt Nagaur

N= 101

MSI COT

N= 253

Govt UP

N= 122

No problem, I would have gone elsewhere

46.5% 38.3% 48.4%

Further to travel 42.6% 31.2% 36.9%

More expensive 3% 3.6% 3.3%

I could not get the method I like

1% 4.7% 4.9%

I could not get any method

4% 13.4% 3.3%

Other problem 3% 7.5% 2.5%

Don’t know 0% 1.2% 0.8%

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