Public Reproductive Health Facilities : A Client-Satisfaction Survey

Introduction: Understanding clients’ perspectives on quality improvement programs is essential to achieve the goals of health services. Determining client satisfaction could help decision makers to implement programs fit to their needs as perceived by service providers and clients. This study aimed to assess the level of satisfaction among women attending health centers regarding the services received in governmental health facilities in Shiraz, southern Iran. Method: This cross-sectional study was performed in 24 urban health centers. Using systematic random sampling method, 8 clinics were assigned to each group. Then questionnaires were distributed among 240 married women in 15-49 year-old age group who had referred to selected clinics for receiving some services. For data analysis, SPSS version 15 software and Chi-square statistical procedure were used to evaluate clients’ satisfaction. Results: Data showed that 101 out of 240 respondents were completely satisfied with the personnel as well as the health center. Furthermore, satisfaction was found to be the highest among clients of those centers ranked as middle class socioeconomic status, while no significant difference was found between centers based on their socioeconomic status. Conclusion: The results of the present study would enable policy-makers to effectively improve the quality of health care, keeping a balance between providers’ and patients’ perspectives on the quality of health care.


Introduction
Access to a range of safe and effective services is considered as human right and also a key determinant of reproductive health outcomes (Abdal & Aday, 1996;Aldana et al., 2001).Understanding clients' perspective and considering their feedback and opinions in quality improvement programs is essential to achieve the goals of health services (Azim & Kolsoom, 2004;Couper, 2004).
Client satisfaction is an important component of quality of care (Creel et al., 2002) and its measurement has become an integral part of health facility management strategies (Farhad et al., 2006).On the other hand, the evaluation of client perception of service quality is a common concern of health managers, researchers and policy makers (Hassan & Pourali Reza, 2003, James, 2001).Determining client satisfaction help decision makers to implement programs tailored to client needs as perceived by service providers and clients (Margolis, 2003).
In fact, client satisfaction is the level of satisfaction that client experience by using a service and reflects the gap that might exist between the expected service and experience of the service, from the client's point of view (Matthew, 2001); A satisfied client is more likely to develop a deeper mutual relationship with their provider, leading to improved compliance, continuing of care (Mendoza et al., 2001).

2003).
In Iran public health services are provided through a nation-wide network which is established based on primary health care (PHC) system.In this system, health centers in urban areas are staffed by one or more general practitioners, health technicians, midwives and administrative personnel .The urban health centers are supervised by a district health network (Ramarao et al., 2003;Rao, 2006).
Few studies have been conducted on client satisfaction in reproductive health services in Iran.As client satisfaction is one of the important indicators of quality of primary health care and its performance, this study aimed to assess the level of satisfaction in women attending health centers regarding the aspects of the services they received in governmental health facilities in Shiraz, capital city of Fars province.In this study, different aspects of reproductive health services which may have strong effects on client satisfaction such as accessibility of services, privacy, continuity of care, health providers' interaction with clients, information received by clients, cleanliness, and presence of suitable and adequate equipment were evaluated.

Methods and Materials
A cross-sectional study was performed in urban health centers located in Shiraz, Iran.According to the approved regulations by Ministry of Health and Medical Education (MOHME) in 2007, each urban health center should cover an average of 12500 individuals living in cities.Given averagely 5 members in each family, each urban health center should deal with at least 800 active files.Each file is considered to be active if at least one visit is recorded in the last one year.The personnel of an urban health center include one midwife (as the Head) and 3 health technicians.Urban health centers' activities include preconception care, prenatal care, post-partum care, neonate and child care, vaccination as well as providing couples with family planning counseling and devices.
There were 86 urban health centers in Shiraz, Iran.At first we categorized urban health centers into high, middle and low socio-economic (SE) groups according to their addresses.Using systematic random sampling method, eight clinics were assigned to each group.Then a trained questioner went to these 24 centers and distributed the questionnaires among 240 married women in 15-49 year-old who referred to selected clinics for receiving some care.The questionnaires were distributed among the study population, after a consent form was signed by them.
The questionnaire was composed of three parts; data of the urban health center characteristics, demographic information of the woman who filled the questionnaire and 6 questions for discovering client satisfaction regarding each clinic.The first part was composed of the clinic's name and address, number of personnel, active files and covered population.The second part was composed of her age, level of education, and career.The third part included questions regarding the urban health house and its personnel.To Estimate client satisfaction in each center, respondents were asked about the average time (in minutes) that took from their house to the urban health center, the mean waiting time for receiving the requested service/services, and the cleanliness of the center.At last, they declared their satisfaction regarding the confidentiality and privacy, friendliness and respect of the personnel as well as the average time used for each service.For scoring, traveling time from client's house to the clinic was categorized in three groups; desirable time (15 minutes or less) scored 1, acceptable time scored 0.5 (16-30 minutes) and unacceptable time scored 0 (more than 30 minutes).The required time for receiving the requested service was considered in three groups; desirable waiting time (20 minutes or less) graded 1, acceptable time (21-40 minutes) graded 0.5, unacceptable time (more than 40 minutes) graded 0. Other four questions were scored 1 if the client was satisfied and 0 if she was unsatisfied.

Statistical Analysis
For analyzing data we used SPSS version 15, while P value less than 5% was considered significant.We used Chi-square statistics for testing the difference between education, career, and age group among the centers according to their SE status.We also used Chi-square statistics to confirm the difference in clients' satisfaction between centers with high, middle and low SE status.

Results
Since some of the returned questionnaires were incomplete, we distributed 278 questionnaires to receive 240 complete ones, so the response rate was 86.3%.the mean age of study participants was 28.5±5.7 years, while the youngest and the oldest ones were 16 and 47 years old, respectively.225 out of 240 (93.8%) were housewives and the rest were employed.Of the respondents, five (2.1%) had a post graduate-degree, 32 (13.3) held bachelor's degree, while 101 (42.1%) finished high school, 27 (30.1%)passed primary or guidance school and 30 (12.5%) were illiterate.Furthermore, most of the educated respondents belonged to the high SE group.Detailed information is shown in Table 1.Note. 1 SE: socio-economic; 2 Chi 2 statistics was administered.
According to clients' answers, most of them (231; 96.3%) reported that they had no problem with finding a health center in their first attendance, regardless of the center's SE status.Most clients (193; 80.4%) stated that the distance between their home and the health center was less than 15 minutes, and they were satisfied, while 9 (3.8%) were dissatisfied because it took more than 30 minutes, however the highest rate of dissatisfaction was found among clients with low SE group.Besides, 176 (73.3%) respondents said the waiting time was desirable (less than 20 minutes) and the highest rate of satisfaction was found among individuals who had registered in a high SE health center.As a part of the client satisfaction questionnaire, we asked the participants about cleanliness and appearance of health centers.198out of 240 respondents (82.5%) thought the heath center to which they had referred, had acceptable appearance and cleanliness, while satisfaction was reported to be the highest among clients of low SE group.Also, clients were asked about the quality of their interaction with health personnel.234 (97.5%) respondents were satisfied with the way health personnel treated them regardless of SE class of health houses.its seal of approval was given by the answers given to two other questions in which most participants reported that they felt relaxed to talk about their private issues (203; 84.6%) and the personnel allocated enough time to describe their problems (225; 93.8%).At last, we evaluated client satisfaction regarding the centers they referred.Data showed that 101 out of 240 respondents were completely satisfied with the personnel and the center they attended.Furthermore, satisfaction was the highest among clients of the centers ranked as middle SE, while there was no significant difference in total satisfaction score among different centers based on their SE classes (P value=0.9, 3 P value=0.9 Note. 1 SE: socio-economic; 2 Chi 2 statistics was administered; 3 T test was used.

Discussion and Conclusion
This study highlighted client satisfaction in urban health centers in Shiraz, Iran.Client satisfaction is undoubtedly a useful measure, and it may provide a direct indicator of healthcare quality based on clients' accurate assessments.
In our study, most clients (96.3%) claimed that they had no problem with finding a health center in their first attendance, regardless of the center's SE status while client satisfaction was not significantly related to finding a health center in a study done by Margolis (Scholle et al., 2000).Most clients in our study (80.4%) admitted that the distance between their home and a health center was less than 15 minutes, while (3.8%) were dissatisfied because it took more than 30 minutes.This was in consistence with the results of similar studies done by Jaffari and Smith (Shadpour, 2000;Smith, 1999).
Furthermore, reducing waiting time for receiving the requested service (to 30 minutes) was of great important to clients.In the present study, (73.3%) of respondents said the waiting time was desirable (less than 20 minutes) and the highest rate of satisfaction was found among individuals who had registered in a high SE health center while in some other studies waiting time was the only element with which users of outreach services were partly dissatisfied (Shadpour, 2000;Stephen, 2003).Also, Smith found this item to be statistically significant (Smith, 1999).As a part of the client satisfaction questionnaire, we asked participants about cleanliness and appearance of health houses.(82.5%) of respondents thought the health center to which they had referred, had acceptable appearance and cleanliness.This was in agreement with a similar stud done in England in which cleanliness was reported to be a significant element of client satisfaction (Smith, 1999).
The most powerful predictor for client satisfaction with government health services was health personnel behavior toward clients, particularly their confidentiality and friendliness.In the present study (97.5%) of respondents were satisfied with the quality of their interaction with health personnel and the way health personnel treated them regardless of SE class of health centers that was consistent with other studies in which this aspect was much more important than the technical competence of providers for clients while Smith found no statistical significance which did not agree with our results (Shadpour, 2000;Smith, 1999;Stephen, 2003).
Another study finding that clearly differentiates patients' views about quality from those of providers relates to physical examination.In our study most clients reported that the personnel allocated enough time to describe their problems (93.8%) while in Alanda's study that was done in the united Arab Emirates only 29% of clients underwent a physical examination, and only 16 out of 1913 clients interviewed stated that they expected a thorough physical examination from the provider (Stephen, 2003).
Data showed that most respondents were completely satisfied with the personnel and the referred health center which is in convergence with similar results showing an acceptable satisfaction score (Shadpour, 2000;Stephen, 2003;WHO, 2004;WHO, 2008).The results of the present research will enable policy-makers and decision-makers to improve the quality of health care effectively, keeping a balance between providers' and patients' ideas of what quality of health care means.
The main limitation of the present study was that only governmental health centers which delivered certain services were included; the authors suggest that in further research private health centers should be included as well in order to compare the services provided in governmental and private health centers.

Table 1 .
Demographic information of study participants

opinion about the time dedicated to them by health personnel
Table 2).