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The Net Promoter Score (NPS) metric, commonly used by Fortune 500 companies to measure the customer experience, is calculated using a 0-to-10 scale to answer 1 question: "How likely is it that you would recommend [company X] to a friend or colleague?" Despite the value of this methodology as a predictor of growth and indicator of customer satisfaction in for-profit industries, uptake of the NPS has been slower in the social sector due to concerns about its applicability and acceptability in noncommercial settings, particularly among low-literacy populations. To address these concerns, we conducted a series of small-scale pilots in El Salvador, India, Kenya, and Nigeria to test different implementation approaches of the NPS in sexual and reproductive health clinics-including face-to-face interviews, a guided drop box, integration of the NPS question into an existing client exit interview, and self-administered and volunteer-assisted online surveys using tablets in clinics-and compared the traditional 0-to-10 number scale with an emoji-face scale. Findings showed that the NPS can be effectively adapted for use in low-resource health clinics among low-literacy clients using the number scale. There was no statistically significant difference in mean likeliness to recommend services when using the emoji versus numerical scales in India; however, there was a statistically significant difference when using the guided drop box approach versus face-to-face interviews. When combined with demographic and service-use questions, the NPS generated useful insights on client groups that were more or less likely to recommend the services. While providing an online survey on tablets can be an efficient methodology for implementing the NPS, self-administered approaches may be limited by a client's level of literacy or comfort with technology. For those client populations with a lower NPS, we advise using a qualitative feedback process that can elicit critical feedback to identify actions to improve their experience. Our experience with testing and implementing the NPS in SRH clinics in diverse settings suggests it is a promising approach to gaining insight into the client experience in nonprofit health care settings.

The Net Promoter Score (NPS) for Insight Into Client Experiences in Sexual and Reproductive Health Clinics