Introduction

In Portugal, 94% of women of childbearing age use a contraceptive method, with oral hormonal contraceptives the method of choice (76%) (DGS, 2018). However, 84% of them acknowledge that they have already forgotten to take the pill and 47% intend to change their method to one that does not require daily use, such as long-term reversible contraception (Bayer, 2017).

Currently, young people start their sexual activity earlier and have later maternity projects (^{Magalhães, 2007}; ^{Águas, Bombas & Silva, 2016}), which leaves them more exposed to the risk of an unplanned, unwanted pregnancy, infections sexually transmitted diseases and the voluntary interruption of pregnancy. According to the Report on the Records of Voluntary Pregnancy Interruptions, the total number of pregnancy interruptions by the woman's choice in the first 10 weeks was 14 899, 96.2% of total abortions performed in Portugal in 2018 (DGS, 2018). Regardless of the reasons given for a voluntary interruption of pregnancy, what is at its origin is non-adherence to contraceptives, discontinuity, incorrect use and unmet needs for family planning (Águas, Bombas & Silva, 2016; ^{Palma, 2017}). When asked, women are able to list several contraceptives, but with little knowledge about them, and this information is based on beliefs and internet research (^{Greene, Joshi, & Robles, 2012}; ^{Matias, 2015}; Águas, Bombas & Silva, 2016; Palma, 2017).

There is a perceived need to promote contraceptive counselling as a way to protect women from experiencing an unplanned and unwanted pregnancy, which can expose them to difficult economic and family situations. Prevention is an important line of intervention in the context of promoting health. There is a deficit in contraceptive decision making related to beliefs, cultural aspects, poverty, poor health literacy, difficulty in access to services and to health professionals and services, such as low availability, inefficient service response (OE, 2011) and lack of preparation on the part of professionals (OE, 2011; ^{Bellizzia, Nagaic & Sobel, 2020}; ^{Palma, Presado & Ayres-dos-Santos, 2021}).

In a literature review (^{Palma, Taborda, Nunes, Cardoso, & Presado, 2020}), we found that quality contraceptive counselling favours adherence to contraceptive methods in general, and in particular to long-term reversible methods, which are considered the most efficient. Health professionals do not always provide counselling and when they do, it is very heterogeneous, the available resources influence the quality of response of professionals and services, which are often adapted to the individual case. The quality of counselling depends on the professional's qualifications and counselling should be centred on the needs of women (Palma, Taborda, Nunes, Cardoso, & Presado, 2020; Palma, Presado & Ayres-de-Campos, 2021).

Internationally, since the 1990s, there has been a concern with the quality of care in family planning motivated by a recognition that the women’s positive experiences with health professionals are essential for choice and adherence to a contraceptive (^{Holt et al., 2019}). They are also essential for promoting trust in the health system (^{Kruk et al., 2018}; Holt et al., 2018). Portuguese law states that family planning consultations and distribution of contraceptives are free in the national health system. However, there are accentuated regional inequalities in terms of access, which means the most disadvantaged, in addition to unmet needs for family planning, lack of information, poor adherence to consultations for contraceptive counselling, use of less effective methods or incorrect/discontinued use (^{Presado, Palma & Cardoso, 2018}; Palma, 2017; ^{Águas, Bombas & Silva, 2016}).

Promoting quality contraceptive counselling, which promotes women’s literacy in decision-making and adherence to adequate contraception for their needs is paramount. This issue led us to conduct a survey to measure the quality of care in contraceptive counselling. To this end, our research focused on the Quality of Contraceptive Counselling Scale, 22 Items (^{Holt et al., 2018}) as it met our requirements.

Studies carried out by ^{Holt and his colleagues (Holt et al., 2018}), found that providing high quality contraceptive healthcare is based on communication between the person receiving care and the healthcare professional. This interaction should be based on the exchange of information and interpersonal relationships (Holt et al., 2019). These researchers conducted studies in order to learn about best practices in contraceptive counselling, health communication and respect for human rights (Holt, Dehlendorf & Langer, 2017). Consequently, they developed the Quality of Contraceptive Counselling Scale (QCC) in order to assess the interaction of the person’s experiences with health professionals during quality contraceptive counselling (Holt, Dehlendorf & Langer, 2017).

The aim of this study is to adapt the QCC culturally and to assess the psychometric qualities of the Portuguese version of the QCC, i.e. the QCC-PT. Research Question: To what extent will the QCC-PT have adequate psychometric qualities to assess the quality of contraceptive counselling?

1. Methods

We started by requesting permission to translate, adapt and validate the QCC Scale to the Portuguese population, from the author, Kelsey Holt from the University of California at San Francisco. Permission was received on 18 June 2020. We then employed the translation/retranslation methodology (^{Beaton, Bombardier, Guillemin, & Ferraz, 2000}), which comprises six stages: translation, synthesis, retranslation of the questionnaire (back translation), review by a committee of experts, pre-test and verification of the psychometric properties.

1.7 Validation of the QCC-PT Scale.

The psychometric qualities of the QCC-PT, which were assessed through the validity and reliability (^{Coutinho, 2014}) of the scale and its three dimensions individually in a sample of 200 women. The response rate was 86%, resulting in a final sample of 172 questionnaires (n=172), between August and November 2020 using the same inclusion criteria as the pilot study.

Analysing the responses QCC-PT, eight questionnaires were eliminated as they were not correctly filled in (duplicate responses or no response), without verifying a pattern in the responses given, nor in the type of participants. Data analysis to assess the psychometric qualities of the QCC-PT was performed using the R® Software (The R Project for Statistical Computing) (R Core Team, 2020), more specifically, the estimation of the factorial model was performed using the “Lavaan” Package (Latent Variable Analysis) Version 0.6-7 (Yves ^{Rosseel, 2012}).

The analysis of the sensitivity of the items was evaluated using the asymmetry (g1) and flatness (g2) coefficients, considering that the items with absolute values, no higher than 3 and 7 respectively, do not deviate from normality; that is, they have psychometric sensitivity (^{Marôco, 2014}; ^{Curado, Marôco, Vasconcellos, Gouveia & Thoyre, 2017}). Construct validity was assessed using factorial and convergent validity, using confirmatory factor analysis, with robust weighted least squares (RWLS) estimation. For the QCC-PT Scale to be considered valid, we consider that all the constituent items should have factor weights above the reference value (0.40). The quality of the model’s fit to the data was assessed using empirical indices: Chi-square test statistics of fit (χ2/df) < 5, Comparative Fit Index (CFI) and Tucker Lewis Index (TLI) greater than 0.9 Root Means Square Error of Approximation (RMSEA) less than 0.05. The reliability of the created dimensions was estimated using Cronbach’s alpha considering an acceptable reliability if α ≥ 0.70. The composite reliability (CR) and the mean extracted variance (MEV) were calculated as indicators of convergent validity, where CR ≥ 0.70 and MEV ≥0.50 (Marôco, 2014).

The reliability estimate was based on the mean correlations between QCC-PT items, weighted by the respective variances. Reliability was considered acceptable if ᾳ ≥ 0.70. We also consider a composite reliability (CR) ≥ 0.70 and an extracted mean variance (AVE) ≥ 0.50 as indicators of convergent validity. With regard to discriminant validity, we considered that it was present for factors in which the VEM was greater than the square of the correlation between factors (^{Marôco & Garcia-Marques, 2006}; Marôco, 2014).

In the first phase of the study, the factorial model of the QCC-PT, consisting of three dimensions and 22 items, adjusted to the sample of 172 women, presented poor quality of adjustment values (χ2/df = 2,566; CFI= 0, 869; TLI= 0,853; RMSEA = 0,097, P(RMSEA ≤ 0,05) < 0,001 . So, the initial model was refined.

Items 2, 3, 4, and 10 were removed from dimension one (Information Exchange). It initially had 10 items and now has 6. Items 13 and 14 of dimension two (Interpersonal Relationship), from seven initial items, it is now composed of 5. In the third dimension (Disrespect and Abuse), item 18 was removed, with four items remaining in the end, having had 5 initially. There was a need to refine the initial model because they presented sensitivity problems with high skewness values and kurtosis coefficients (|g₁|>3 e | g₂| >7) and low factorial weights (< 0,4).

The modified QCC-PT scale consists of 15 items and three dimensions: Information Exchange (IE), with six items; Interpersonal Relationships (IR), with five items; and Disrespect and Abuse (DA), with four items. The IE dimension reflects the information that women are given about contraceptive methods and follow-up options, as well as the information they share with healthcare professionals about their preferences and needs. The IR dimension covers items related to privacy, confidentiality, respect, trust and empathy and the DA dimension includes the way health professionals treat women, discrimination and physical abuse (Table 1).

Table 1 Descriptors of the information exchange (IE), interpersonal relationship (IR) and disrespect and abuse (DA) dimensions 

2. Results

The psychometric qualities of the modified QCC-PT were evaluated by calculating the sensitivity, robustness and reliability of the items of the three dimensions of the scale for a sample of 172 women who were included in the previously established eligibility criteria. The women were aged between 21 and 30 years, were mostly Portuguese, single and with secondary education. In table 2, the following statistical results of the items on the QCC-PT scale are presented: medians, maximums, minimums, shape measures (g₁ and g₂), as well as their critical ratios.

Table 2 Median, maximum, minimum, shape measures (asymmetry - g₁ and kurtosis - g₂), with the respective critical ratios (g₁/SEg₁ and g₂/SEg, for the 15 items of the QCC-PT scale (n=172). 

The factorial weights of each dimension of the QCC-PT scale and the Cronbach’s Alpha per dimension are presented in table 3. The internal consistency of the IE dimension presents Cronbach’s Alpha values = 0.86, less high than the IR dimension (Cronbach’s Alpha = 0.89) and the DA dimension (Cronbach’s alpha = 0.87). The CR in the three dimensions is: CRIE = 0.863; CRIR = 0.901 and CRDA = 0.87. The convergent validity estimated through the VME ranges between (IE) 0.52; (RI) 0.65 and (DA) 0.629. All values are above the reference.

Table 3 Factor weights obtained through confirmatory factor analysis and internal consistency (Cronbach’s alpha) of the three factors of the QCC-PT 

The correlations between IE and IR and between DA and IR are of medium magnitude and the correlation between DA and IE is negligible, as shown in table 4.

Table 4 Pearson correlation among the three dimensions of the QCC-PT scale 

There is a negative correlation between the DA dimension and the other two, which was to be expected. This fact is related to the way the questions are formulated in the DA dimension.

Figure 1 shows the models with the three factors of the QCC-PT with the respective factor weights and goodness-of-fit indices that support the dimensions of the scale (Figure 1).

Figure 1 Confirmatory factor model of the QCC-PT scale 

3. Discussion

Using the conventional methods of translation and adaptation of questionnaires, it was possible to develop a version of the QCC scale adapted to the Portuguese reality - the QCC-PT scale. In the first stage of the study, the factorial model of the QCC-PT, consisting of three dimensions and 22 items, adjusted to the sample of 172 women, presented poor quality of adjustment values (χ2/df = 2,566; CFI= 0,869; TLI= 0,853; RMSEA = 0,097, P(RMSEA≤ 0,05) < 0,001. The initial model was thus refined.

The reliability of the three dimensions of the QCC-PT presents good Cronbach’s Alpha values, and it can be said that the scale presents good internal consistency with a standardized alpha higher than the reference. For CR we considered values above 0.70 as a good reliability indicator, which was observed in this scale (CRIE = 0.863; CRIR = 0.901 and CRDA =0.87). Convergent validity, assessed through average extracted variance (AEV) presented values above the reference values (AEVIE = 0.52; AEVIR = 0.65 and AEVDA =0.629).

Of the three dimensions of the scale, only IE and IR, which are positively correlated with correlations of moderate intensity and statistically significant (p<0.001). The correlation between the DA and IE dimension is negative and negligible, i.e., only statistically significant at the 5% level (p = 0.044) and the correlation between DA and IR is moderately negative and statistically significant (p < 0.001). The negative relationships are due to the way in which DA issues are formulated in relation to IE and IR issues.

The final adjustment of the QCC-PT model is good with all factor weights above the reference value (0.40) and the goodness-of-fit statistics showing good values (χ2(87) = 174,756; p < 0,001; n = 172; χ2/df = 1,698; CFI = 0,959; TLI = 0,951; RMSEA = 0,064, P[rmsea ≤ 0,05] > 0,10). Thus, as shown in figure 1, dimension 1 with 6 items, 2 with 5 and 3 with 4 items, allows us to conclude that this scale has factorial validity, sensitivity and reliability in the sample.

The QCC-PT contributes to assessing women’s experiences with health services and professionals during contraceptive counselling. With this scale, health professionals can assess and propose improvements in the quality of contraceptive counselling provided to women receiving care. This assessment is carried out in three dimensions: information exchange, interpersonal relationships, and disrespect and abuse. The QCC scale, developed by North American researchers and applied in Mexico, provides steps for high quality contraceptive counselling that respect the principles of human rights such as privacy, confidentiality, non-discrimination, as well as concepts of communication in health including respect, empathy and trust. Considering the great importance of this type of instrument, the scale was applied to a group of Portuguese women in its modified version and has adequate sensitivity, reliability and factorial validity, so it can be considered an instrument that should be used, not only in its practical component during contraceptive counselling, but also in research. The adjustment of the factorial model allows us to propose a modified version of the instrument (QCC-PT), to be used to identify problems and propose adjusted interventions and in partnership with the women receiving care.

Conclusion

The purpose of contraception is to protect women from unwanted pregnancies. The quality of contraceptive counselling is essential to ensure that these pregnancies occur less often. It is known that a large number of women who undergo a voluntary interruption of pregnancy were using contraception, which denotes the existence of flaws in the counselling provided by health professionals. The choice of a contraceptive must be based on knowledge and the main source of information is based on quality contraceptive counselling that guarantees women’s rights, sociocultural and economic aspects, promotes and respects choice, proper use and continuity of the selected method. We consider it essential to know how women perceive the counselling given to them in order to suit their individual reproductive needs.

We found a lack of Portuguese studies that assess the quality of contraceptive counselling provided to the population, which is why we consider validation and cross-cultural adaptation of the QCC-PT to be pertinent, as it allows us to assess the three most important dimensions of the quality of contraceptive counselling: information exchange, interpersonal relationships, and disrespect and abuse. The scale allows the assessment of women’s experiences during contraceptive counselling. Thus, it is an important instrument to assess and improve this care in Portugal.