The Medical Journal of Basrah University

Study Methodology

This study is a cross-sectional study with Health facility exit face to face interview conducted in Basrah during the period from 1 st of March to 15 th of May 2012.

Subjects:

The participants were women aged 15-49 years living in Basrah.

Sampling and sample size:

The following steps were adopted for selecting the study sample size for each of the target groups:  The geographic area in which the study was done was identified to include all Basrah Health Districts (8 districts).  The following types of health facilities were included in the study: Hospital) was divided by 50 (the total number of health facilities planned to be included in the study). The sampling interval was calculated to be 2.6  Choosing the first point where to start the study sampling was done by rounding the sample interval up to the nearest full number to be (3) followed by choosing a random number between 1 and this number (in this case 1, 2 or 3). And this was done by using the latest figure of the number on a paper money banknote.

 To identify the next facility to be included in the sample, the sampling interval was added to the previous result, and rounded up to find the facility number to include. The first sample chosen was facility 2 from the sampling list, the next facility selected was number 5 (2 + 2.6 = 4.6, rounded up to 5) and the process continued until all facilities were selected.  Accordingly, data from 53 health facilities and 265 women's exit interviews were collected during the study  The selection of women also followed a random selection method: every fifth woman aged 15-49 years registered at the reception to have a gate pass seeking a service in the health facility, was interviewed after walking out of her medical visit. A total of 5 women were selected from each health facility.  Client exit interviews were conducted after the client has received services to ensure that the interviews will obtain information from the client's perspective on the services received that day. An explanation was made prior to each interview that the aim of the interview is future improvement of the quality of care that is provided at the health care facility and that their comments will be used only for that purpose. Data were collected by direct interview. Each interview took 45 to 60 minutes.  A quick check before leaving each facility check list was made to ensure that all the questions were asked and all answers were recorded. By the end of each day, all forms were re-checked for completeness.  A pilot study was conducted first to test the feasibility of the study and the time required to complete it. The questionnaires were tested on ten facilities.  Statistical analysis: The collected data were processes in the computer and the statistical used, is the SPSS version 20.0 Set.

Tool for data collection:

A client satisfaction and knowledge assessment questionnaire was used that has been structured after an extensive literature review and discussions with the technical group of the experts in Reproductive Health and Family Planning. Health facility exit face to face interview was used for reaching the study objectives.

RESULTS

( The reason for attendance Table-3, presents the distribution of the respondents based on the last reproductive health service utilized by them(the current visit at the day of interview or within two weeks before) .The table shows that 155(58.5%) of the respondents were visiting the health facility for antenatal care and 52 (19.6 %) were attending for a child's vaccination. On the other hand, only 10 (3.8%) were visiting the health facilities for a family planning related cause(6 to receive their contraceptive pills or hormonal stimulating drugs, 2for infertility management and 2 for Intra Uterine Contraceptive Device follow up exam), 4 (1.5%) for breast mass, and 1(0.4%) for post natal care. In addition, 24(9.1%) were attending for follow up investigation and treatment of anemia. In addition, 10 women (3.8%) were attending for other causes (4: Follow up and investigation for Renal complaint, 1: Blood pressure measurement, 1: Menstrual pain, 2: Hemorrhoid and 2: Hernia). The use of family planning methods Figure-1, shows that 43 (16%) of the total respondents reported that they were currently using contraception, of whom 22(51%) were getting the service from private sources and the remaining from public governmental sources (10 from governmental hospitals and 11 from primary health care centers); Figure-2. (Figure-3), shows that 73(27.5%) of the interviewed respondents were completely satisfied with the service they received in addition to 166 (62.6%) of them were partially satisfied with it, with only 26 (9.8%) of the respondents were dissatisfied. With respect to causes of dissatisfaction, 47 (17.7%) of the respondents mentioned crowding of the place in which the service is provided as a major cause of their dissatisfaction, while 38 (14.3%) mentioned the bad attitude of the service providers as the cause of their dissatisfaction.

Satisfaction of the service users with the provided care

Deficiency of drugs/ supplies was mentioned by 14(5.3%) of the dissatisfied respondents, 10(3.8%) stressed on the issue of having "no privacy" as the main cause while "presence of no female doctor" was mentioned by 8(3%) of them; (Figure-4

DISCUSSION

The majority of the service users found by the study were attending the health facilities seeking for antenatal care and child vaccination while the least number of them were attending for family planning causes. This might be explained by the previous knowledge of the users that they won't find their needed family planning service in the facility they are attending. On the other hand, it was found that screening and management of sexually transmitted infections/Acquired Immune Deficiency Syndromes, gender based violence and youth health services were the least services that women knew about their availability at the studied health facilities. In consideration of the family planning services, the overall countrywide contraceptive prevalence was about 32% in 2000 with wide disparity (4.8%-47%) between provinces and a lot of women were using traditional ways. [14] The present study found that only 16% of the study respondents were currently using a contraceptive method. While according to the ministry of health annual statistical report (2013), the contraception prevalence rate in Basrah was 54.4% compared to the national rate of 52.2%. A study done in Dohuk district of Kurdistan region in 2003, found that the prevalence of contraceptive use (any method) among 668 non-pregnant women was 60.6%. [15] In a more recent resource, the United Nations Population Fund (UNFPA) and World Health Organization, stated that:" Family planning services in Iraq need more improving efforts considering the 2011 indicators which shows that the rate of modern contraceptive prevalence was 28%". [16] The present study included a question asking the target population if they had a history of exposure to physical violence from a male in the family including husband, brother, father or other relative living in the same house during the past 2 years preceding the study. It was found that the prevalence of physical domestic violence against women to be 7.5%. According to Iraq Family Health Survey (2006/2007), prevalence of physical violence was reported to be 21.2 % for Iraq and 22.7% for the centre/south area of the country. [17] Studying the users' satisfaction with the provided reproductive health services helps the policy makers together with the service providers to understand the user's opinion and judgment about the service they received. [18] In the present study, respondents were found to be satisfied with the service provided. Dissatisfaction was reported by only less than 10% of the respondents and that was mainly because of the crowding of the place, while no privacy and presence of no female doctor were the least among the list of causes. In a client exit study on satisfaction with primary health care services and perception of antenatal care and child care in Basrah done by Abt Associates Inc. in 2004, it was found that 79.8% of the study group was either satisfied or very satisfied with the services received. Only 2.4% expressed dissatisfaction or unacceptability of the services. [9] Assessing and understanding the service users' perception and service preference (whether public or private), is a crucial step for achieving a better client oriented service that target the users' requirements and needs together with fulfilling the client expectations. [19] In the present study, public health facilities were preferred to be always the type of services they seek when having problems during antenatal period, labour and post partum period. While they preferred to use the private sector when having any problem related to their family planning use. A study done in Erbil to assess women's views and experiences of antenatal care, it was found that women preferred seeking private sector during their antenatal period due to their negative experience with the antenatal care services at the primary health care centers and they usually prefer to go to private doctor's clinic for antenatal care. [20] Conclusions & Recommendations:

 Antenatal care and child vaccination were the main causes for attending the health facilities, while family planning was the least cause for attendance. On the other hand, screening and management of screening and management of sexually transmitted infections/ Acquired Immune Deficiency Syndromes, gender based violence and youth health services were the least services that women knew about their availability at the studied health facilities.  The majority of the service utilizers were satisfied with the provided services. The main reason for dissatisfaction reported by those who were dissatisfied was the overcrowding. Public health facilities were always preferred for seeking help for any problem during antenatal period, labour and post partum period. While the private sector was preferred for receiving family planning services.  For the purpose of improving users' service utilization, service users should be aware about the available reproductive health services in addition to their importance in their life. A special focus should be made to encourage men's involvement especially in relation to family planning counseling. Community awareness should include in addition, religious leaders, school teachers and college students in order to guarantee mass spread of the messages.

Table 3 . The reason for the current respondent's visit to the health facility Causes of the visit No

Table 4 . Respondents' choice for seeking medical help during antenatal, natal, postnatal periods and for family planning services