Person‐centred sexual and reproductive health: A call for standardized measurement

Abstract Person‐centred sexual and reproductive health (PCSRH) care refers to care that is respectful of and responsive to people's preferences, needs, and values, and which empowers them to take charge of their own sexual and reproductive health (SRH). It is an important indicator of SRH rights and quality of care. Despite the recognition of the importance of PCSRH, there is a gap in standardized measurement in some SRH services, as well as a lack of guidance on how similar person‐centred care measures could be applied across the SRH continuum. Drawing on validated scales for measuring person‐centred family planning, abortion, prenatal and intrapartum care, we propose a set of items that could be validated in future studies to measure PCSRH in a standardized way. A standardized approach to measurement will help highlight gaps across services and facilitate efforts to improve person‐centred care across the SRH continuum. Patient or Public Contribution This viewpoint is based on a review of validated scales that were developed through expert reviews and cognitive interviews with services users and providers across the different SRH services. They provided feedback on the relevance, clarity, and comprehensiveness of the items in each scale.


| INTRODUCTION
Access to respectful, person-centred sexual and reproductive health (PCSRH) services is a fundamental human right and critical to ensuring equitable care globally. The achievement of PCSRH is dependent on the realization of sexual and reproductive health (SRH) rights-the rights of individuals to make decisions governing their bodies and to access services that support those rights and includes among other things the rights of all individuals to bodily integrity, privacy and personal autonomy. 1 While there has been a growing recognition of the need for respectful, person-centred care, there has been a critical lack of consensus on how to measure this across 2 | WHAT IS PCSRH?
We define PCSRH as care that is respectful of and responsive to people's preferences, needs and values, and which empowers people to take charge of their own SRH. This builds on the definition of patient-centred care from the US Institute of Medicine (National Academy of Medicine since 2015), which highlights person-centred care as a key domain of quality of care. 2 This last part of the definition draws on the World Health Organization definition of integrated people-centred health systems, which emphasizes 'empowering people to take charge of their own health rather than being passive recipients of services' and 'putting people and communities, not diseases, at the centre of health systems'. 3 PCSRH is thus care that promotes reproductive autonomy, is free of reproductive coercion, elevates individual's decision-making and is supportive and empowering. Domains of PCSRH include dignity, communication, autonomy, privacy, confidentiality, social support, supportive care, trust and the health facility environment. 4,5 We have chosen to use the term 'person-centred' over 'patientcentred' as per discussions that 'patient' tends to objectify and reduce the person to a mere recipient of medical services, or to 'one who is acted on'. 6 Person-centred care highlights the importance of 'knowing the person behind the patient-as a human being with reason, will, feelings and needs-to engage the person as an active partner in their care and treatment'. 6 The term 'person-centred' is also inclusive of family and significant others who are often codecision-makers in whether and how people seek and use care.
Although the singular terminology highlights the specific needs and preferences of the care seeker, people-centred care is also an appropriate terminology to capture these social networks. In addition, people-centred care as used in the WHO terminology highlights the responsiveness of the health system to the community, which is inclusive of individual needs. 3 Regardless of terminology, this concept highlights respect for individuals of all backgrounds and identities, including treating people with dignity, respecting their privacy, keeping their health information confidential, providing sufficient information for people to make informed decisions about their care, providing emotional and social support and valuing their individual preferences and diversityemphasizing the interpersonal and experience dimensions of care. 2,4,7 For example, person-centred decision-making is an approach to shared decision-making predicated on the need for clinicians to understand and respect the patient as a person to fully engage with the patient's experience of illness and participation in their treatment.
This then allows clinicians to provide supportive care that respects a person's autonomy. 8

| A LIFE COURSE PERSPECTIVE OF SRH
A life course perspective moves beyond the traditional understanding of reproductive health, which tends to focus only on contemporary risk factors and the independent nature of these risks. 9 The life course perspective, on the other hand, considers the entire life span of an individual, the continuity of reproductive health care and the temporal order of exposures. 9 Past studies have found that early life exposures are linked to later reproductive health outcomes; and women's reproductive health is linked to previous generations and predictive of later chronic conditions, such as cardiovascular diseases and cancers. 10

| BENEFITS OF PCSRH
Person-centred care, and by extension PCSRH, has direct and indirect effects on health outcomes by influencing health-seeking behaviour, self-efficacy, patient engagement, timely and appropriate care, safety and improved psychosocial health. [12][13][14] For example, mistreatment of women during childbirth deters women from giving birth in health facilities, [15][16][17][18] while providing continuous support during childbirth is associated with shorter labour, increased likelihood of spontaneous vaginal delivery, lower anxiety, better coping with pain and increased rates of breastfeeding initiation. 19 Information-sharing and positive interpersonal interactions can increase the adoption and continuation of modern family planning methods. 20 (Table 1). Although there are some differences in the type and number of items across these scales, scores on all the scales can be standardized to range from 0 to 100, with higher scores indicative of more person-centred care. For example, for maternity care, the total standardized scores for surveys conducted in Kenya, Ghana and India were all below 70 out of a total of 100. 40 Scores on the family planning scales were at 70 for Kenya and 87 for India, 26 while for abortion, scores were in the range of 83-86 for medication and surgical abortion, respectively. 29

| GAPS IN PCSRH
The domain with the most prominent gaps across settings and SRH outcomes was Communication and Autonomy. Similarly, high proportions of women surveyed in Kenya and India on their family planning and abortion experiences reported providers did not introduce themselves. 26,29 Additionally, more than one out of T A B L E 1 Summary of person-centred care scales across family planning, abortion, and maternity care. a

Scale
Context # of items Subdomains  24-31,40 b This is an experience of care index that includes several generic person-centred care questions as well as questions specific to antenatal care procedures.
The items were not based on a formal process of scale development and validation. c For intrapartum care. three women surveyed in Kenya, Ghana and India reported they were not asked for consent for examinations and procedures during childbirth. 40 These findings highlight gaps in person-centred care at various stages of the SRH continuum that need to be addressed. These measures should be included in routine national data collection systems for ongoing monitoring and intervention efforts. Most importantly, measurement should facilitate efforts to improve PCSRH and person-centred care more broadly, as evidence-based interventions to improve person-centred care are urgently needed.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest

DATA AVAILABILITY STATEMENT
Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.