Editorial Board:
Editor:
George H. Conklin,
 North Carolina
 Central University

Board:
Rebecca Adams,
 UNC-Greensboro

Bob Davis,
 North Carolina
 Agricultural and
 Technical State
 University

Catherine Harris,
 Wake Forest
 University

Ella Keller,
 Fayetteville
 State University

Ken Land,
 Duke University

Miles Simpson,
 North Carolina
 Central University

Ron Wimberley,
 N.C. State University

Robert Wortham,
 North Carolina
 Central University

Editorial Assistants

John W.M. Russell,
 Technical
 Consultant

Austin W. Ashe,
 Duke University

® 

Volume 8, Number 1

Spring/Summer 2010

A  Study of Relationship between Socio-economic Factors and Satisfaction with Family Planning Services in Iran

by

M. T. Iman
Shiraz University

and

Shafieh Ghodrati
Tehran University
 

Introduction

    In Iran, population control policies were initially implemented by the government in 1967. Because of Islamic revolution and following fundamental changes, the control policies were stopped. Under the influence of demographers warnings about population growth, Islamic government tried to revive population policies in 1989 (Abbasi-Shavazi 2005). Since then, family planning services have been greatly supported by the government and interpreted as important components of health services. Population data indicate that family planning programs have been successful in Iran: population growth rate decreased from 3.25% in the early 1981 to 1.62% in recent years (Statistic Center of Iran 2007). Moreover indices of reproductive health such as infant mortality, mother mortality and infants underweight have declined (Shahidzadeh et al. 2003). 

    Based on key objectives and main concerns, developments in international family planning programs can be divided into four periods. Using modern contraceptives began in 1990s. During the decade, meeting demands and availability of methods were the focal points of programs. In the following decade using more effective methods and also creating demand were followed as the most important objectives. Furthermore accessibility of services was the main concern. In 1980s motivation of potential users and diffusion of information and technology as well as acceptability of services became the central goals of programs. Finally, the key objectives of the next decade were satisfaction of users and removal of medical and social barriers. Also the main concerns were benefits and acceptability of users (Tavaraw 1997: 9).

    Improving quality of care has come to the forefront for two main reasons. First, family planning administrators increasingly realized that enhancing contraceptive prevalence has a limited effect on fertility rates if quality of care is lacking. A. K. Jain, a leading expert on family planning, has said: "Without significant attention to quality, we will neither see a sustained increase in the contraceptive prevalence rate nor succeed in lowering birth rates through voluntary means". In other words, programs would have greater impact if rather than putting undue emphasis on recruitment, they took better care of the users they already had (Hardon et al. 1997: 7-8).

    The second reason for paying more attention to quality of care has been put forward by women's health advocates. The women's health movement challenged the rationale of population programs aimed at reducing fertility in developing countries. Such programs stress that limiting family size is a societal responsibility that takes precedence over individual well-being and rights. Women's health movement strongly criticized population programs and emphasized on increasing the number of contraceptive acceptors to reach targets and resulting reduction in fertility rates (Ibid). Women's health advocates call for services that respect woman's reproductive and sexual rights, provide balanced information and offer a free and informed choice among a wide rang of methods (Becker et al 2007: 207).

    We viewed client satisfaction as a key outcome of quality of care, as well as a key component of sustainability. Thus, measuring client satisfaction can be a useful way of evaluating certain aspects of quality, and increases in satisfaction may indicate improved quality (from the clients' perspective) and better prospects for sustainability. (Williams et al. 2000: 63).

    Hence, high-quality services ensure that clients receive the care that they deserve. Furthermore, providing better services attracts more clients, increases the use of family planning methods, and reduces the number of unintended pregnancies. Several studies have shown that improving the quality of reproductive health services increases contraceptive use. Studies in Bangladesh, Senegal, and Tanzania showed that women's contraceptive use was higher in areas where clients felt that they were receiving good care than it was in areas with lower-quality health facilities (Creel et al. 2002:1).

    After International Conference on Population and Development in Cairo in 1994, numerous constituencies have articulated their ideas of how family planning services should be organized and rendered. The common theme behind their visions is that services should be responsive to the needs of individual clients (Rama Rao and Mohanam 2003:228). Emphasis was placed on principles of freedom and respect for individuals in the spheres of reproductive matters and on importance of women gaining greater independence in such matters (Trovato 2002: 318) . 

    In this section, some important theories and models that explain satisfaction are reviewed. Then conceptual and empirical framework of this research would be presented. 

    In recent years, Jonathan Turner has sought to integrate a variety of theoretical traditions - primarily, symbolic interactionism, expectation states, and psychoanalytic theory - into a more general theory of emotions (Turner 2006).

    He argued that in all situations, people carry expectations or, if they did not have them on entering the situation, they soon develop them. These expectations come from a variety of sources, such as norms and values, relative authority or prestige of individuals, needs which are aroused in situations, past memories of what transpired in past interactions, density of network ties among individuals, and other forces. The important point is that these expectations become part of individuals' definition of situation, especially with respect to what should be transpired. Emotions are aroused when expectations are met, exceeded, or unmet. As a general rule, when people's expectations are not realized, they will experience negative emotions, or various combinations of anger, fear, and sadness. In contrast, when individuals' expectations are realized, they will experience variants of satisfaction and happiness, and if they are exceeded, people generally will feel variants of happiness (Turner 2003: 448).

    Judith Bruce developed a framework specifically for assessing the quality of family planning care. Bruce's framework remains highly relevant to service programs today, and has emerged as the central framework from which family planning programs are evaluated. Bruce attempts to incorporate both technical and interpersonal aspects of care in measuring the quality of care provided in family planning programs (Strobino et al. 2000: 7).

    Bruce considers elements of quality as those activities which are done by an organization. Eventually regarding inputs and activities the impacts of family planning programs are as follow: increasing clients knowledge about methods of fertility control, individual's health during contraceptives use, clients satisfaction, acceptance and continuation of using methods. He illustrates the elements of quality of care as follows:

Choice of methods refers both to the number of contraceptive methods offered on a reliable bases and their intrinsic variability.

Information given to clients refers to the information imparted during service contact that enables clients to choose and employ contraception with satisfaction and technical competence. 

Technical competence involves, principally, factors such as the competence of the clinical technique of providers, the observance of protocols, and meticulous asepsis required to provide clinical methods such as IUDs, implants, and sterilization. 

Interpersonal relations are the personal dimensions of service and relations between providers and clients.

Mechanisms to encourage continuity can involve well-informed users managing continuity on their own or formal mechanisms within the program.

Appropriate constellation of services refers to situating family planning services so that they are convenient and acceptable to clients (Bruce 1990: 63-4). 

    Since in this research quality of services is measured through the viewpoints of clients, we can argue that if clients believe a quality of services is high it implies their satisfaction with the services. Therefore six elements of quality of services may be construed as elements of clients' satisfaction.

    The theoretical framework for the study of access to medical care provided the conceptual model for testing use of prenatal care services (utilization) and satisfaction with the services .So, the framework is health services utilization model which are used to study the access concept. It has largely been used to study access to medical, dental, and hospital services. The main assumptions of this framework are as follows: An individual's potential to enter or have access to health care services is determined by the characteristics of the health care delivery system as well as a health care consumer's needs, desires, and resources. And the actual entry or access into the health care system is an indicator of health care utilization and satisfaction with the care received. Utilization of health care services and consumer satisfaction are considered to be outcomes of access. In addition, utilization of health care services is conceptualized as influencing satisfaction with the services, and the degree of satisfaction experienced influences the frequency with which health care services are used. Characteristics of the population at risk are delineated as predisposing, enabling and need. Predisposing characteristics are those that exist prior to an illness that describes the propensity to use health care services. Examples of predisposing characteristics are attitude toward health care, employment status, and educational level. Enabling characteristics refer to resources available that influence the use of health care services. Examples are regular source of care and income level. Need characteristic refers to perceived health status. Consumer (patient) satisfaction is defined as attitudes of consumers regarding health care services received once contact has been made with a service (Aday and Andersen 1974). The dimensions of consumer satisfaction as hypothesized by Aday and Andersen (1974) are satisfaction with convenience of care, availability, cost, provider characteristics such as courtesy, information provided regarding the illness, and health care consumers' overall assessment of the quality of health care received.

    Utilization is considered to be an objective measure of the level and pattern of a health care system. It is defined in terms of type, site, purpose, and time interval. Time interval refers to contact, volume, or a continuity measure. Contact refers to an individual's entry or nonentry into the health care system within a given time interval. Volume is the total number of visits within a given time interval, and continuity is the degree of individual linkage and coordination of services associated with a specific illness or episode (Ivanov and Flynn 1999).

    Another theoretical framework offered by practitioners to explain satisfaction with services is business framework. There are two major streams of business-oriented satisfaction research have been developed. First, the SERVQUAL stream hypothesizes that customers evaluate service quality on five dimensions: physical cues; reliability; assurance; responsiveness; and empathy. The SERVQUAL model argues that client satisfaction is best represented as differences between the attribute-level service quality clients generally expect and their evaluations of the service attributes received. Such analyses enable managers to identify specific service attributes (e.g., reliability or empathy) on which the provider meets, fall below or exceed client expectations. Evidence for the model in health-care settings, however, is mixed. The second major business stream, focuses directly on customer satisfaction. Customer satisfaction is most often defined as an overall feeling of satisfaction or dissatisfaction that immediately follows a service encounter. Unlike many healthcare approaches which equate service quality with satisfaction, the consumer framework explicitly models service quality evaluations as cognitive antecedents to the affective construct of visit satisfaction. As such, this framework allows identification of service quality dimensions that are most strongly related to client satisfaction. In addition to service quality evaluations, consumer satisfaction is hypothesized to be influenced by customer expectations; subjective disconfirmation (overall comparisons of what was expected to what was delivered; akin to the discrepancy model from the health-care literature); and emotions experienced during service use.

    The first hypothesis is that cognitive processes of evaluation during the clinic visit will predict feelings of satisfaction immediately following the visit. This hypothesis is based on attitude theory stating that, under most conditions, cognitions primarily play an antecedent role in affective response.

    In the above model, pre-visit expectations of clinic service quality (measured at the attribute level) and post visit perceptions of actual clinic performance (also measured at the attribute- level) are directly related to post-visit feelings of satisfaction. In addition, they hypothesize that expectations and performance evaluations influence consumer satisfaction indirectly through subjective disconfirmation (the degree to which overall perceived clinic performance was better than, equal to, or lower than what was expected by the client) (Alden et al. 2004: 2221-2)

    According to Bruce framework, satisfaction with services includes six elements of qualities (choice of methods, information given to clients, technical competence, interpersonal relations, mechanisms to encourage continuity and appropriate constellation of services). Among these elements we don't regard technical competence of providers in the research model because the clients don't have enough knowledge and competence to evaluate this aspect.

    Based on Alden et al framework and Turner theory, individual satisfaction of received services depends on the degree of her expectations as an intermediate variable in the model. Also two other variables of Turner theory are helpful for our model: individual's social status and experience of previous interactions. So, client's social status and their previous experience with family planning center are two variables which indirectly affect satisfaction.

    Based on Aday and Andersen framework, job status, education and income are directly related to satisfaction. So, client's socioeconomic status directly influences satisfaction.

    Finally, we regard level of clients' knowledge about contraceptive as an intermediate variable in a model. This variable has relationship with socioeconomic status, experience of previous interactions and affects expectations. 

    Considering the above illustrations conceptual model of the present research can be seen in the Figure 1.

Figure 2 shows the causal relationships between independent variables and satisfaction of services as dependent variable. 

Bring up Large Image in New Window

    A sample of 380 women aged 15-59 years of Shiraz city was interviewed. These women were the clients of family planning centers. It should be noted that there are 30 family planning centers. Based on socioeconomic status of geographical location in which the centers were placed, we divided all centers into three levels. Considering the population proportion of threefold socioeconomic region, the number of centers was determined. Finally a sample of 15 family planning centers was fixed. Then some skilful interviewers, administrated questionnaires out of centers in calm and confident conditions. Interviewees were the women who were returning from center.

    Some of the questions for measuring satisfaction with services elements were as same as used in Strobino et al's research (Strobino et al. 2000). Strobino et al completely explained approaches and indices necessary for measuring components of quality of services and developed a questionnaire in the case. We used that questionnaire with some modifications regarding previous studies. Through the execution of pretests, the reliability of scales was realized. Cronbach's alpha was 0.73 for satisfaction scale and 0.85 for expectations scale. Pearson coefficient and multiple regression were applied to examine relationships between variables. 

    As Table 1 illustrates, 51.3 percent of women were aged 26-35 years and about the 90 percentage of the women were household. 2.7 percent of all respondents were illiterate. The education level of 9.7 percent was primary school, 20.1 percent, secondary school, 48.1 percent high school and 19.5 percent diploma and higher. The percentage of women who had no children or one was 40.1. This implies that a considerable number of clients came to centers for postponing their first or second pregnancy and regulating their fertility behavior.

    Table 1 shows, level of respondents' knowledge about contraceptives. The highest knowledge about contraceptives belongs to condom – 64.3 percentage of all respondents – and the lowest belongs to spermicide – 4.9 percent. 

    Table 2 and 3 present components of satisfaction. Table 2 illustrates that respondents were satisfied with "provider treated with respect and courtesy" item more than with any other items. In contrast, they showed the leas satisfaction with the item of "receiving written information". Clients' expectations were mainly met in regard with "receiving requested method" while most of the women expressed that their expectations were not met relating to "receiving written information". Table 4 presents the result of hypothesis test. Except the relationship between age, family income and education with dependent variable, other relationships were significant. Among independent variables, number of children ever born, number of unintended pregnancies and being affected by side effects had a negative impact on satisfaction with services.

    Table 5 and Figure 3 demonstrate direct, indirect and total impacts of independent and intermediate variables on satisfaction of services. Variables have been ordered according to their impacts on dependent variable. All independent variables except the number of unintended pregnancies, duration of using services and number of children ever born, entered in the path analysis model. Path coefficients show that variables including expectations and age, affect dependent variable directly without any indirect impact. Three variables have both direct and indirect influences on satisfaction with services. They are as: degree of knowledge about methods, number of children ever born and degree of side effects; while duration of using services, family income, education and job rank affected dependent variable just indirectly. The highest total impact is expectations. Degree of knowledge about methods is the second influential variable; however, the least impact belonged to family income. All independent variables entered in path analysis model affect dependent variable positively except family income and side effects variables which have negative impact on satisfaction of services. Two other variables of social status ( education and job rank) are directly related to dependent variable while income influenced it reversely. The value of e2 for satisfaction of services is 0.45 and for level of knowledge about methods and meeting expectations are 0.76 and 0.8 respectively.

    Women's satisfaction of family planning services is an important factor of continuation of using services by them. Therefore measuring clients' satisfaction is a useful method to evaluate quality of services. When clients satisfaction rise, it implies that from their point of view the quality of services has been improved. Since 1990 clients' satisfaction is considered as a main concern in international family planning community.

    The purpose of this research is investigating clients' level of satisfaction of family planning services and its socioeconomic and demographic determinants. Results show that seven out of ten hypotheses are retained. Independent variables including job rank, number of children ever born, number of unintended pregnancies, duration of using contraceptives, being affected by side effects, expectations being met, degree of knowledge about contraceptives have significant relationships with dependent variable  (satisfaction of services). However there are not any significant relationships between family income and family education as well as women's age with their satisfaction. Two most influential factors are expectations which have been met and side effects of using contraceptives. While the first affect is positively the seconds' impact is negative.

    Path diagram demonstrates that women's age as an independent variable affects satisfaction with the path coefficient of 0.113. Thus as women's age rise, their satisfaction with services would be increased. One suggestion for this result is that providers treat more kindly with aged women than the young. Other suggestion can be related to aged people dispositions. For example, their satisfactions may be achieved more easily than that of young women. As new generations have experienced more changes, we can argue that the aged women socialization had been in the way that they think they should not criticize provider's behavior. This result is in accordance with some other researches finding such as Nakhaee and Mirahmadzadeh (2005) as well as Taik Sung's (1977).

    The socioeconomic status (couples' income, couples' education and average mean couple's job rank) of the respondents indirectly affect their satisfaction. While the first one of these three variables has positive impact on satisfaction the other two variables influence women's satisfaction negatively. It seems that women's with higher education have higher level of knowledge about contraceptives which in turn brings about more satisfaction with services. This result is as same as Nakhaee and Mirahmadzadeh's findings (2005). Regarding the negative impact of income on satisfaction, it should be noted that the income impact is through the level of women's knowledge of contraceptives. Women whose family income is higher, exhibit lower level of knowledge about contraceptives. Consequently lower knowledge about contraceptives decreased women's satisfaction of services. 
The effect of job rank on satisfaction is indirect. It means that its impact is through knowledge of contraceptives and expectations. We can argue that women with higher family's job rank have more information about contraceptives and their expectations are mainly met. The path coefficient depicts that job rank is most influential variable on satisfaction. 

    In sum, the indirect impact of social status, confirms Tuner's theory. As we noted in Turner's theory, socioeconomic status just indirectly influences on individual's satisfaction. However this research shows that the impact of social status components are not in the same direction. This finding is in contrast with that of Nakhaee and Mirahmadzadeh's research (2005). More detailed investigations are needed to clarify relationship between income and satisfaction.

    Two variables extracting from the "previous interaction experience" concept – a concept of Turner's theory- did not entered into the path analysis. They are number of unintended pregnancies and duration of contraceptive use. To explain the first one we can argue that women were facing with unintended pregnancies, adopt themselves with it, so that its negative impact on their satisfaction of services have decreased.

    Another variable which influences women's satisfaction both directly and indirectly was side effects. Women who had undergone more side effects, had more expectations which were not met and consequently their satisfaction were declined. For direct influence, it can be said that those women who experience more side effects, attributed to low quality of services and their satisfaction decrease.

    Women's knowledge about contraceptives as an intermediate variable have significant affect on dependent variable, so that their satisfaction of services rises with their knowledge increase. Generally women, who were more aware of contraceptives, choose more suitable and effective methods. As a result their satisfaction was higher than the others.

    Another intermediate variable which have a significant relationship with satisfaction is expectations being met. As women's expectations are met, their satisfaction of services rise. This finding supports Turner's theory in which expectations is an intermediate variable influencing satisfaction. In Afkham Ebrahimi (2004) and others' study as well as Ross' research (2006) the relationship between expectations and satisfaction is as present study.

    The research findings indicate that 50 per cent of respondents are dissatisfied with some options including: "receiving written information", "receiving suitable alternative method", waiting time in centre", "become aware of side effects", "concerning about their information being overheard", "consult time" and "receiving oral information". Therefore we suggest the providers of family planning centers to pay more attention to these aspects of services.
Furthermore, women's expectations relate to options such as "receiving written material", waiting time in center", and "become aware of side effects" have been met in a low level. So we suggest providers to take these aspects of services in consideration.

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