A local consultant has been hired by an international reproductive health research organization to conduct research on family planning service delivery. Her job is to design and manage a clinic-based study to measure standard indicators of quality of care. She realizes that a critical component of the research will be observation of client—provider interactions. 

With her intimate knowledge of the local health system, the consultant realizes that the observers she must hire and train will need to strike a balance between neutral observation and advocacy for client welfare. In fact, during the pre-test of the observation data collection instrument, she observed many instances of poor-quality care. For example, some providers failed to mention side effects of the clients’ chosen method or they answered clients’ questions erroneously. She did not intervene in these situations. However, she began to worry about how her observers should handle more serious problems they might witness, such as providers’ failure to wash their hands between pelvic exams or before insertion of an IUD. 

Questions: (Click on the question to reveal possible answers.)

1. What guidelines would you give observers for safeguarding client welfare? Is there a point at which intervention is warranted?
   
   
2. How should neutral researchers react when they observe mistakes, lapses and misinformation in the context of a study to assess quality of care?
   
   
3. Quality of care assessments and performance evaluations are often exempted from the informed consent standards applied to clinical research. What, if any, informed consent procedures should be required of clients? Of providers?