Women’s Voices in Open, Inclusive Communities and Effective Spaces (VOICES) includes 71 items measuring women’s empowerment regarding maternal and reproductive health. The social accountability measure evaluates CARE’s Community Score Card approach to women's empowerment. The items measure women’s perception of their surrounding environment through four aspects: women’s attitudes and beliefs about gender roles, household power dynamics, social cohesion and collective efficacy, and structural and cognitive social capital.
Geographies Tested: Malawi
Populations Included: Female
Age Range: Adolescents, Adults
Knowledge & awareness of rights
1. A healthcare provider can refuse to provide me healthcare because of my age.*
2. The government of Malawi ensures that maternal and child health services are provided free of charge.
3. The healthcare provider is required to keep my healthcare information private and confidential.
4. I have a right to complain if a healthcare worker yells at me or is disrespectful.
5. Healthcare providers are required to answer all my health-related questions.
6. Every individual has the right to prompt emergency treatment from the nearest public or private facility.
7. I do not have the right to complain about the quality of health services in this community.*
8. Community health workers (for example, HSAs) should visit pregnant women and now mothers/ babies at home.
Response Options:
5-point Likert scale
Strongly agree - 5
Strongly disagree - 1
Rejection of intimate partner violence
Is a husband justified in hitting his wife if…
9.…she goes out without telling him?
10.…she neglects their children?
11.…she argues with him?
12.…she refuses to have sex with him?
13.…she did not cook the food properly?
Response Options:
Yes - 1
No - 0
Belief in women’s right to refuse sex
Is a woman justified in refusing to have sex with her husband if…
14.…she knows he has a sexually transmitted disease?
15.…she knows he has sex with other women?
16.…she has recently given birth?
17.…she is tired?
18.…she is not in the mood?
19.…she is unhappy with her husband?
Response Options:
Yes - 1
No - 0
Healthcare decision-making
Which member of your household usually makes decisions about…
20.…your healthcare?
21.…whether you and your husband use family planning?
22.…where you will deliver your baby?
23.…when you will go to a health facility to deliver your baby?
24.…if you will be tested for the AIDS virus?
Response Options:
You - 2
Your husband - 1
You & your husband together - 2
Mother- or father-in-law - 1
Mother or father - 1
Or someone else - 1
Abbreviated household decision-making
Which member of your household usually makes decisions about…
25.…your healthcare?
26.…making large household purchases?
27.…making household purchases for daily needs?
28.…when you will visit family/relatives/friends?
29.…when your whole household will visit family/relatives/friends?
30.…how to use the money that you bring into the household?
31.…how to use the money your husband brings into the household?
32.…how many children you will have?
Response Options:
You - 2
Your husband - 1
You & your husband together - 2
Mother- or father-in-law - 1
Mother or father - 1
Or someone else - 1
Self-efficacy for attendance
How sure are you that you could attend a community meeting if…
33.…your family did not encourage you to go?
34.…your family did not want you to go?
35.…your family would not help with your household duties so that you could attend?
Response Options:
5-point Likert scale
Completely sure - 5
Not at all sure - 1
Self-efficacy to speak out
How sure are you that you could express your opinion…
36.…at a community meeting?
37.…at a community meeting if some people did not agree with that opinion?
38.…at a community meeting if most people did not agree with that opinion?
Response Options:
5-point Likert scale
Completely sure=5
Not at all sure=1
Outcome expectations for participation
If you attended a community meeting, how sure are you that...
39....you would be treated fairly by the other participants?
40....your opinion and suggestions would be taken into consideration?
Response Options:
5-point Likert scale
Completely sure - 5
Not at all sure - 1
Self-efficacy for service utilization
How sure are you that you could go to the health facility if...
41....you were worried that the staff would treat you badly?
42....your husband objected to your going?
Response Options:
5-point Likert scale
Completely sure - 5
Not at all sure - 1
Outcome expectations for service utilization
The staff at [health facility]…
43.…is friendly and treats me well.
44.…gives me all the information I need to take care of my health.
45.I often have to wait a long time to receive care at the health facility.
Whenever I go to the health facility, …
46.…there is a provider available to serve me.
47.…it rarely has the supplies and medicine I need.
48.…the staff involve me in decisions about my care.
Response Options:
5-point Likert scale
Strongly agree - 5
Strongly disagree - 1
Perception of service quality
49. The staff at [health facility] provides high quality health services.
50. The staff at [health facility] ensures privacy and confidentiality when providing services.
51. The health facility is clean.
52. Men are welcome to accompany their wives during pregnancy and delivery care.
53. A family member or friend is welcome to accompany a woman during delivery.
54. Unmarried women can access family planning & reproductive health services at the health facility.
Response Options:
5-point Likert scale
Strongly agree - 5
Strongly disagree - 1
Community support in times of crisis: when pregnant and bleeding
How sure are you that there is someone in your community – apart from your immediate family – who…
55.…you could turn to for advice?
56.…could take you to the hospital?
57.…would help care for your children or household while you are away?
58.…would loan you money for transport?
Response Options:
5-point Likert scale
Completely sure - 5
Not at all sure - 1
Social cohesion
I can rely on people in my community…
59.…if I need to borrow money.
60.…to help deal with a violent or difficult family member.
61.…to help take care of my children/household if I need to go to the doctor or hospital.
62. The majority of people in this community can be trusted.
63. The majority of people in this community generally get along with each other.
64. I feel that I am really a part of this community.
Response Options:
5-point Likert scale
Strongly agree - 5
Strongly disagree - 1
Collective efficacy
How sure are you that the people in your community could work together…
65.…to improve maternal & newborn health services in this community?
66.…to improve how women are treated at the health facility?
67.…to obtain government services & entitlements?
68.…to improve the health and well-being of women and children in this community?
Response Options:
5-point Likert scale
Completely sure - 5
Not at all sure - 1
Social participation & collective action
In the past 6 months, have you…
69.…been an active member in any organized group in your community, for example a women’s group, a religious group, or other community group?
70.…received help from any organized group in your community, for example a women’s group, a religious group, or other community group? Help could include emotional support, economic assistance, or helping you to learn or do things.
71.…joined together with other people in your to improve health services for women or children?
Response Options:
Yes - 1
No - 0
*Items are reverse scored
Knowledge & awareness of rights: Item scores are summed to obtain a total score.
Rejection of intimate partner violence: If ‘no’ to all then scored as 1, otherwise scored as 0. Index of 1 indicates hitting is not justified under any circumstance.
Belief in women’s right to refuse sex: Item scores summed. Scale score of 6 indicates a woman is justified in refusing sex in all situations.
Healthcare Decision-making: Item scores summed and divided by number of items.
Abbreviated Household Decision-making: Item scores summed and divided by number of items.
Overall Decision-making: Item scores from both the healthcare decision-making and abbreviated household decision-making sub-scales are summed, and divided by total number of items.
Self-efficacy for attendance: Item scores are summed to obtain a total score.
Self-efficacy to speak out: Item scores are summed to obtain a total score.
Overall self-efficacy for participation: Item scores from both the self-efficacy for attendance and self-efficacy to speak out sub-scales are summed, and divided by total number of items.
Outcome expectations for participation: Item scores are summed to obtain a total score.
Outcome expectations for service utilization: Item scores are summed to obtain a total score.
Perception of service quality: Item scores are summed to obtain a total score.
Community support in times of crisis: when pregnant and bleeding: Item scores are summed to obtain a total score.
Social cohesion: Item scores are summed to obtain a total score.
Collective efficacy: Item scores are summed to obtain a total score.
Social participation & collective action: Each item is scored individually
Sebert Kuhlmann, A. K., Gullo, S., Galavotti, C., Grant, C., Cavatore, M., & Posnock, S. (2017). Women's and Health Workers' Voices in Open, Inclusive Communities and Effective Spaces (VOICES): Measuring Governance Outcomes in Reproductive and Maternal Health Programmes. Development Policy Review, 35(2), 289-311. https://doi.org/https://doi.org/10.1111/dpr.12209
Psychometric Score
Ease of Use Score
Formative ResearchQualitative Research
Existing Literature/Theoretical Framework
Field Expert Input
Cognitive Interviews / Pilot Testing
ReliabilityInternal
Test-retest
Interrater
ValidityContent
Face
Criterion (gold-standard)
Construct
KEY
Ease of UseReadability
Scoring Clarity
Length
Evidence-based Measures of Empowerment for Research on Gender Equality (EMERGE)
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