Quality in Primary Care Open Access

Keywords

Abortion, client satisfaction, adolescent, Jimma town

Abbreviations

AOR: Adjusted Odd ratio; BBHC: Bocho Bore Health Center; CI: Confidence Interval; CSA: Central Statistics Authority; EDHS: Ethiopian Demographic Health Survey; FGAE: Family Guidance Association Ethiopia; JH2HC: Jimma Higher 2 Health Center; JHC: Jimma Health Center; JUSTH: Jimma University Specialized Teaching Hospital; KMs: Kilo meters; MKHC: Mendera Kochi Health Center; MOH: Minster of Health, NGO: Non-Governmental, OR: Odd ratio; SHGH: Shanen Gibe Hospital; UNFPA: United Nations Population Fund; UNICEF: United Nations Children's Education Fund; WHO: World Health Organization

Background

Adolescence (Age 10-19 years) is transitional stage of physical and psychological development that occurs from puberty to adulthood. One of the contributions of research in the quality field has been its attempt to define what is meant by quality care.1

Access to quality, safe abortion services prevents mortality and morbidity among women and constitutes an integral part of comprehensive reproductive health. There is a proven link between unsafe abortion and increased maternal mortality and morbidity as well as higher healthcare costs2 46 million women around the world have induced abortions each year, 78 % of whom live in developing countries but maternal mortality from abortion is a preventable, as evidenced by statistics from countries with either access to legal, safe abortion or effective harm reduction models.2,3

Patient satisfaction is an important and commonly used indicator for measuring the quality in health care as it affects clinical outcomes, patient retention, and medical malpractice claims. Patient satisfaction is thus a proxy but a very effective indicator to measure the success of care providers and facilities.4

On the other hand, one of the problems continuously faced these days is lack of quality health care and gaining client satisfaction, which are of responsibilities of the higher authorities and staffs in the health care system.5 Evaluating the clients satisfaction with health services is clinically relevant, as satisfied patients are more likely to comply with treatment, take an active role in their own care, continue using medical care services and recommend center‘s services to others. 6 A satisfied patient will recommend center‘s services expressing their satisfaction to four or five peoples, while a dissatisfied will complain to twenty or more.7 The quality of RH care is critical in determining whether the service meets clients’ expectations or not, for instance the have choice of services, get accurate and complete information, technically competent care, good interaction with providers, continuity of care, and constellation of related services.8

A study conducted in Maharashtra and Rajasthan on Comprehensive Abortion Care showed as most of the quality dimensions have a positive and the predictors were provider behavior, assurance regarding follow-up, medical information and waiting time in obtaining services, background factors, is residence.9

The study conducted in Mexico City where the Six domains of quality of care (client-staff interaction, information provision, technical competence, post abortion contraceptive, accessibility and facility env’t) were assessed and findings showed respectfulness, protecting privacy , sufficiency of information , good technical skill , convenience of working hours , waiting time and cleanness of the facility were associated with higher overall scores.10

Study conducted in Tigray showed only 40.6% of clients were satisfied and this satisfaction was associated with educational, occupational status, laboratory prescription and toilet access. Only 48 % of them were informed about availability of family planning and supplied with, 88.3% of the clients did not get opportunity to pose questions or concerns.11 Quality maternal care must be appropriate, satisfactory, low cost and accessible service that makes women capable of choosing a healthy life.12

In countries where provision of abortion is restricted or low quality or inaccessible, women often resort to unsafe methods that results in complications, long-term health problems or even death as abortion care” is more than just an abortion procedure and it is a comprehensive approach comprising: counseling, safe abortion services and other RH services, like diagnosis and treatment of STIs or addressing needs of women subjected to violence.3

To the knowledge of the investigators, there is no study on client satisfaction with abortion services in the study area where the abortion service utilization was prevalent, and different higher institution like Jimma University which has more than 40 thousand students, Jimma University Teaching and specialized hospital, Jimma teacher training College, South west Military campus. Thus, this study is proposed to assess the clients’ satisfaction with the services among clients coming the facilities for abortion and post abortion services

Methods and subjects

The study was conducted in Jimma town health facilities from April - May 2015. Jimma town is one of the towns in Oromia located 352 Kms Southwest of the capital city Addis Ababa. The total projected population of the town from 2007 Central Statistical Agency (CSA) census report is 128,330. The governmental health institutions in Jimma town are 2 hospitals and 4 health centers and Non-governmental working on maternal health like Family Guidance association Ethiopia and Marie Stopes International. Total number of women of child bearing age as estimated from the total populations of town in the 2007 population and housing census of Ethiopia comprises 33,373.13

Facility based cross-sectional with quantitative method of data collection was used. The population for this study are all sampled adolescent visiting health institutions in the town for abortion and post abortion sleeted by simple random sampling after allocating the sample size proportionally for each of health facilities in the town and all abortion service providers at each selected facilities purposively based on their position, closeness to activities, experiences to assess the facility related issues like presence of protocol on the service provision, mechanism they use to control quality, training , qualification as the clients are not know / tell us the points. The data was collected by four Midwives , diploma in qualification who have previous experience on data collection using pre-tested semi structured questionnaire ( the questionnaire consist of both close and open ended ) adapted from Donabedian’s Model of quality, Bruce’s Quality of service Model and Bergström quality of maternal care and questions were grouped according to the particular objectives that they address and 3 point Likert Scale which ranges between 1 and 3; scale( 1= Agree , 2 =Neutral , 3= Disagree) the scores for each domain were calculated by summing the answers to all items in each domain :interpersonal skill (10-30), technical quality (5-15), physical env’t (4-12) , organization of health care (8-24) and clients' overall and component wise satisfaction was classified into two categories satisfied and dissatisfied by using cut of point calculated using the demarcation threshold formula: {(total highest score-total lowest score)/2} + Total lowest score.14,15

Data was analyzed using SPSS version 20.0. In addition to descriptive statistics, chi-square test and bivariate analysis were employed to see association between dependent and independent. Then variables having association were entered in to binary logistic regression to obtain OR and the CI and also multivariable logistic regression analysis was carried out to assess strength of statistical association of satisfaction and the determining variables. The strength of statistical association is measured by AOR and 95% confidence intervals. Statistical significance is declared at P<0.05. Finally the result was presented using tables, figures and charts

Ethical considerations

A copy of research proposal was submitted to College of Health Science research coordinating office of Jimma University. Ethical clearance from Jimma University, College of Health Science Institutional Review Board and permission from respective authorities and verbal consent of respondents’ was obtained before the data collection. To get full co-operation, respondents were reassured about the confidentiality of their response. They also ensured their voluntarily participation and right to take part or terminate at any time they wanted.

Results

The data were collected from a total of 228 adolescent visiting health institutions in Jimma town for abortion and post abortion services that makes the response rate 97.4% and 28 abortion service providers from April to May 2015. The results are presented under subheadings as follows;

Socio demographic characteristics the participants

Two hundred eight (91.2%) of the participants were in age group of greater than 17 years with mean of 20.78, std. deviation 2.55, minimum 14 and maximum 24 . As to marital status, 133 (58.3 %) were married. Regarding ethnicity, religion, level of education, residence and occupation, 129 (56.6%) were Oromo, 110 (48.2%) were Muslim, 74 (32.5 %) were preparatory and above by education level, 150 (65.8%) were from Jimma Town and 81 (35.5%) were student by occupation respectively. As to the monthly income of the participants 53 (55.8%) had ≤ to 650 birr mean of 1048.33, std. deviation 817.94, minimum 100 and maximum 4889 (Table 1).

† =Divorced and in relation, ††=Catholic, not want to tell, †††= Tigre, Dawuro, Silte ††††=Daily labor, House wife, NGO, Currently no own job

Table 1: Distributions of study participants by their socio demographic characteristics, Jimma town, April - May 2015.

Personal related factors

As to the personal related factors 269(74.1%) were visited the health facility for abortion, 62 (27.2%) of the participants stated as their reason for abortion was low socio economic status, the most selected procedure was medical abortion which accounts for 145 (63.6%), 86 (37.7%) were not know their care provider by profession and only 92 (40.4%) of them were live with their family (Table 2).

*Unwanted pregnancy, unplanned pregnancy

** Campus students, alone, with female friends

Table 2: Distributions of participants by their personal characteristics, Jimma town, April - May 2015.

Previous Experience of the participants

As to the previous experience of the participants 179 (78.5%) had information on availability of abortion service, 31 (13.6%) had history of previous abortion, 110 (48.2%) had first sexual intercourse at age ≤ 17 years, 45 (19.7%) of them had greater than one sexual partners, 201 (88.2%) had information about family planning of this 136 (67.7%) had history of contraceptive use (Table 3).

**Condom, Implanon, Jadelle

Table 3: Distributions of participants by their previous experience, Jimma town, April - May 2015.

Participants Satisfaction

As to the technical quality of care providers and physical environment of the health facility, the most satisfaction level indicted was the satisfactions rated on advice given by service providers (Table 4).

Table 4: Distributions of participants by their level of Satisfaction with art of care/interpersonal skill, Jimma town, April - May 2015.

Regarding the Organization of health care system, location of the clinic, waiting time of clinic, working hours of clinic, not easiness of getting laboratory service are among the dissatisfying factors the overall satisfaction level was classified into two categories satisfied and dissatisfied by using cut of point calculated using the demarcation threshold formula and 54(23.7%) dissatisfied (Table 5, 6).

Table 5: Distributions of participants by their level of Satisfaction with Technical quality of care providers and Physical environment of the health facility, Jimma town, April - May 2015.

Table 6: Distributions of participants by their level of Satisfaction with Organization of health care system, Jimma town, April - May 2015.

Care provider’s interview

As to physical structure, facilities, equipment, only in 18 (64.3%) of the participants reported as there were written abortion care protocols in their health facility, 15 (53.6%) of them reported as there is no second-trimester abortion services at their facility, only 10 (35.7%) of them reported as their facility ordered or purchased equipment and supplies for abortion services and 20 (71.4) of them reported as their facility provides the service 24hrs, 7days/ week (Table 7).

**Profession of interviewed care providers only Nurse and Midwife any type because physicians who perform this procedures are not staffs, they are students

Table 7: Distributions of Care provider by their responses on physical structure, facilities, availability of equipment in their health facility, Jimma town, April - May 2015.

Administrative structure and Fiscal health

As to the administrative structure and fiscal health 15 (53.6%) were reported the availability of guidelines for when, where and how abortion care is to be provided, availability of clear guidelines on technical competence needed for abortion and availability of performance indicators for evaluating health professionals (Table 8).

Table 8: Distributions of Care provider by their responses on Administrative structure, Fiscal health in their health facility, Jimma town, April - May 2015.

Interventional Management, Coordination and continuity the service

As to the interventional management, coordination and continuity the service almost all of the respondents reported as their facility has indicators to evaluate confidentiality, privacy, and respect during service delivery, functional referral protocols for those women needs other types of care, tailoring each woman’s care to her social circumstances and individual needs, availability PAC services, including emergency contraception and strive for continuity of care and follow up.

Association between dependent and independent variables

There were no statistically significant associations observed between client satisfaction with abortion service and client age, marital status, occupational status, residence, religion, ethnicity, current health status, age at first sexual intercourse, number of sexual partners, reason for abortion, sex of care provider, profession of service providers (Table 9).

Table 9: Distributions of Care provider by their responses on interventional management, coordination and continuity the service, Jimma town, April - May 2015.

On contrary there was significant statistical association (p < 0.05) between client satisfaction with the service and educational level (χ²= 20.236, p=0.000), with whom they live (χ²=9.308, p=0.025), information about family planning (χ²=4.489, p=0. 034), history of family planning utilization (χ²= 4.647, p=0.031), type of contraceptive being used (χ²=9.797, p=0 .044) types of uterine evacuation done (χ²= 15.966, p=0.000), having information on availability of service (χ²=6.275, p=0. .012), history of previous abortion service utilization (χ²=9.156, p=0. .002) (Table 10).

**Significant statistical association as p < 0.05

Table 10: Bivariate and multivariate logistic regression model showing predictors of Client Satisfaction with Abortions Service among Adolescent Visiting Health Facilities in Jimma town, April - May 2015.

Bivariate logistic regression analysis shows being primary (1-8) student were 21.9 % times more likely to be satisfied with the service, UOR of 0. 219; those who live with friends were 35.3% times less likely to be satisfied with the service, UOR of 0. 353, those who had history of family planning utilization were 2.064 times more likely to be satisfied with the service UOR of 2.064, those used injectable contraceptive were 23.0% times less likely to be satisfied with the service, UOR of 0.230, those utilized surgical abortion for evacuation were 28.5% times less likely to be satisfied with the service, UOR of 0. 285, those who had information on availability of abortion service were 3.317 times more likely to be satisfied with the service, UOR of 3.317 , those who had history of previous abortion service utilization were 3.232 times more likely to be satisfied with the service, UOR of 3.232

However; multi-variate logistic regression showed only those their educational level was preparatory and above were 22.0% times less likely to be satisfied with the service than those their educational level was less than preparatory [AOR (95% CI) = 0.004 (0.079 0.619)] and those had medical abortion for evacuation were 23.6 % times more likely to be satisfied with the service than those had surgical methods [AOR (95% CI) = 0.001 (0. .118, 0.471)]

Discussion

Satisfaction and dissatisfaction indicate patients' judgment about the strengths and weaknesses of the service being given for them.10 From this study, almost about one fourth (23.7%) of the clients were not stratified with the service they had.

This finding was not constant with what has been observed in the study conducted in Tigray where only 40.6% of the clients were satisfied with the care they had.11 The likely explanations for this dissimilarity might be difference in sample size, hospital policies, set up, study subjects, socio-cultural difference, health care providers believes, awareness of health, guideline, information on availability of modern tools and disparity in judging satisfaction.

The opportunity given to take part in decisions, equity of treatment, advice given by service providers, availability of service providers and availability of drugs (anti pain) are the points on which the participantices are more satisfied This is constant with what have been observed in the study conducted on 2903 women attending 153 primary health care India Maharashtra and Rajasthan and Mexico on comprehensive Abortion Care were the perceived quality of services were the determined by adequacy of information provided; follow-up discussion ; average waiting time and time spent in consultation, quality of the facility, availability of doctor, availability of visual privacy during consultation, availability of waiting facility, cleanliness of facilities, clients’ background characteristics and state of residence.9,10

This study further revealed the predictors of clients’ satisfaction with abortions service and the factors that have been indicated as predictors are their educational level, with whom they live, information on availability of abortion service, history of previous abortion service utilization, information about family planning, history of family planning utilization, type of contraceptive being used and types of uterine evacuation done.

This result was similar with what had been observed in the study conducted in Tigray governmental hospitals where client satisfaction predictors were educational status and occupational status, laboratory prescription and toilet access, informed about the available family planning methods and supplied with.11

This cross-sectional study has possible limitations that may arise from client readiness and ability to provide every information about themselves and their care and care providers correctly based on which client satisfaction with abortions service was measured and; recall and social desirability bias may be introduced during data collection from the client as they were self-referent. However; measure has been taken to minimize these limitations were using questions targeted information. Moreover, the use of pretested questionnaire and both client and care providers targeted data collection were other strengths of this study.

Conclusion and recommendation

Based on the finding of the study the principal investigators have made the following conclusions and recommendation. This study showed as about one fourth of the clients were not stratified with the abortion service they had .The points on which they satisfied where includes the opportunity given to take part in decisions, equity of treatment, advice given by service providers, availability of service providers and availability of drugs (anti pain). The predictors of clients’ satisfaction with abortions service indicated in this are educational level, with whom they live, information on availability of abortion service, history of previous abortion service utilization, information about family planning, history of family planning utilization, type of contraceptive being used and types of uterine evacuation done and we recommend the responsible authorities (Jimma Zone health office, NGO working on this area), policy makers and interested body have to discuss on this issue to enhance the client satisfaction gap and to develop a system to control client satisfaction and to control factors those affect client satisfaction. Furthermore further prospective studies are recommended in terms of, observational study as it is too key for client satisfaction.

Competing Interests

There no financial and non-financial competing interests and the study was funded by the Jimma University. There have been no reimbursements, fees, funding, nor salary from any organization that depends on or influence the results of this study. The authors do not hold any stocks or shares in an organization that may in any way might be affected by this publication.

Authors' Contributions

SB: contributed in designing the study starting from title selection, prepared methodology part and designed the framework , proposal development and data analysis and wrote first draft of result. FY: approved the proposal and result with some revisions, participated in data analysis and interpretation, drafting the manuscript and revising it critically. Both of authors read and approved the final manuscript.

Acknowledgement

We would like to express our deepest gratitude to Jimma University College of Health Sciences for financially supporting us. Our appreciation also goes to our data collectors, supervisors and study participants for their valuable contribution in the realization of this study.

References

1. Robert H, Elizabeth A, and Paul G. Defining and measuring quality of care: a perspective from US researchers. International Journal for quality in health care 2000; 12: 281-295.
2. RAND, Santa Monica and UCLA Center for the health sciences and the Greater Los’ Angeles Veterans Administration Health care system, Los Angeles, CA, USA.
3. Client Satisfaction with Abortion Services at the National Women’s Hospital Pereira Rossell in Montevideo, Uruguay - 18 Months after Decriminalization
4. Centre for Development and Population Activities 1400 16th Street NW, Suite 100, Washington, DC 20036 USA. A Guide to Providing Abortion Care. www.cedpa.org
5. Bhanu P. Patient satisfaction. Journal of Cutaneous and AstheticSurgery.2010; 3: 151-155
6. Kohan S, Fereydooni J, Mohammad Alizadeh S, Bahramor A. Comparision of Satisfaction rate about mode of providing medical and nursing care. Journal of nursing and midwifery Razi 2003; 3:43-49.
7. Pascoe GC. Patient satisfaction in primary health care: a literature review and analysis. Eval Prog Plan 6.1983; 185- 210.
8. Press I, Ganey R.F, Malone M.P. Satisfied patients can spell financial well-being. Healthcare financial management1991; 45:34-42.
9. Melkamu Y. Ababa and to provide programmatic recommendations. structured questionnaire through client exit
10. Ghosh S, Acharya R, Kalyanwala S, Jejeebhoy S. Understanding client satisfaction: Does quality of care matter? Findings from Maharashtra and Rajasthan. Development Studies, Institute of Development Studies Kolkata, Kolkata, Youth and Adolescent Health, Population Council, New Delhi, India, GHF2008.
11. Becker D, Diaz-Olavarrieta C, Juárez C, García S, Sanhueza P and Harper C. International perspectives on sexual and reproductive health, Guttmacher Institute, Volume 37, Number 4, December 2011,
12. Balem D, Gessessew B and Amare A. Assessment of Quality and Determinant Factors of Post-Abortion Care in Governmental Hospitals of Tigray, Ethiopia, 2013
13. Collins-Fulea C, Mohr JJ and Tilett J. Improving midwifery practice: the American College of Nurse-Midwives Benchmarking Project. Journal of Midwifery & Women’s Health Care 2005; 50: 461-71
14. Central Statistical Agency (CSA), Ethiopia and ORC Macro. 2007.
15. Pitaloka D, Rizal AM. Patients’ satisfaction in antenatal clinic hospital Universiti Kembangaan.Malaysia J Community Health 2006; 12
16. Mehrnoosh A, Yunus AZM, Tajuddin Syed KS, Salmiah H, Said Mohammad B. Patient Satisfaction: Evaluating Nursing Care for Patients Hospitalized with Cancer in Tehran Teaching   Hospitals, Iran.Global Journal of Health Science 2010; 2.