Development of the Adolescent Health Services Quality of Care Index for Mystery Client Studies

The mystery client (MC) methodology is a common quality of care research approach for adolescent sexual and reproductive health (ASRH) services. However, there are gaps in the assessment tools that have been used. The objective of this study was to develop the Adolescent Health Quality of Care (AHQOC) index for the assessment of ASRH services. We carried out a cross-sectional descriptive study in 27 selected primary and secondary public health facilities in a rural and an urban local government area (LGA) in Ogun State, Nigeria. Twelve MCs were recruited and trained for this study, six in each LGA. The selected MC scenarios included young males and females who want information on premarital sex, pregnancy prevention, sexually transmitted infection (STI), and contraception. The data collection instrument was a questionnaire administered to the MCs soon after each MC visit. We used exploratory factor analysis to develop a AHQOC index. The index was tested for reliability with Cronbach’s Alpha test and for intra-rater consistency with the intraclass correlation coefficient test. The Kaiser-Meyer-Olkin (KMO) test results of our initial 37-item pool was 0.7169. Exploratory factor analysis with varimax rotation and communality cutoff of 0.3 retained 27 items. The Cronbach's Alpha of the 27-items scale was 0.80, with two subscales having Cronbach's Alpha of 0.76 and 0.85. The intraclass correlation (ICC) coefficient to assess the intra-rater consistency for the 27-item tool in the predominantly urban LGA was 0.66 (0.10 – 0.92) p=0.001, and 0.72 (0.37 – 0.91) p=0.001 for the predominantly rural LGA. The relationships between the full scales and subscales, and a validity item (MC ranking of health worker on proficiency from 1 (worst) to 10 (best)) were positive, and statistically significant. The tool developed is a valuable and validated tool for assessing quality of ASRH services in public health facilities.