Using cognitive interviews to improve service delivery tools: The simplification of SDM screening

Reproductive health programs rely on job aids with simple algorithms to assist providers to screen clients correctly. The Standard Days Method (SDM), a fertility awareness-based family planning, is most effective for women with cycles ranging 26-32 days, thus accurate screening for cycle length is crucial. This study tests increasing the simplicity of the screening protocol without compromising its sensitivity. Cognitive interviews were applied to 50 women in Ecuador and India, after applying the SDM cycle length screening questions currently used, to measure how women interpret the questions through analysis of their thought processes while answering. Verbal, cognitive probes such as “what does the term ‘period' mean to you,” “what do you think they were asking there,” and “how did you arrive at that answer” were used. It was discovered that correct translation of the term ‘period' to localized terms was very important. Also, many women responded ‘yes' to the screening question, “do your periods usually come when you expect them”, because their periods came soon after spotting, cramping, or other symptoms, however the intended meaning was if they came on or about the date expected. In addition, the screening questions had to be adapted for non-calendar forms of time keeping, such as market days or the moon. These results show that correct translation of key concepts in screening is critical, and cognitive interviews were shown to aid in adaptation. Cognitive interviews have a place, not just in validation of survey instruments, but also in improvement of service delivery tools.