A comparative study on managers', staffs' and clients' viewpoints about organizational and structural obstacles in family planning counseling in health-care centers in Isfahan in 2012.

BACKGROUND: Organizational and structural obstacles are a group of major obstacles in achievement of appropriate family planning counseling. Detection of these obstacles from the viewpoint of managers, staffs and clients who are key members in health services providing system is a major step toward appropriate planning to modify or delete this group of obstacles. The present study was conducted with the goal of comparing managers', staffs' and clients' viewpoints about organizational and structural obstacles in family planning counseling in health-care centers in Isfahan in 2012.
MATERIALS AND METHODS: This is a cross-sectional one-step three-group comparative descriptive study conducted on 295 subjects including 59 managers, 110 staffs and 126 clients in medical health-care centers in Isfahan in 2012. Managers and the staffs were selected by census sampling and the clients were recruited through convenient random sampling. The date collection tool was a researcher made questionnaire, which was designed in two sections of fertility and personal characteristics and viewpoint measurement. Descriptive and inferential statistical test were used to analyze the data.
RESULTS: The obtained results showed no significant difference between mean scores of viewpoints in three groups of managers, staffs and clients concerning organizational and structural obstacles in family planning counseling (P = 0.677). In addition, most of the managers, staffs and clients reported organizational and structural obstacles as the obstacles in the process of family planning in moderate level.
CONCLUSION: The results showed the necessity of health services managers' planning to modify or delete organizational and structural obstacles especially the agreed obstacles from the viewpoint of managers, staffs and clients.

INTRODUCTION

It is estimated that 80 million unexpected pregnancies yearly occur in the world of which 45 million end in abortion.[1] In this direction, appropriate application of family planning is very helpful through reduction of mortality as a result of abortion, achievement to success in the promotion of maternal health, enhancement of women's social position and overall social-economic development.[23] The major causes of unexpected pregnancies are the failure in contraception methods and lack of selecting an efficient contraception method.[4] On the other hand, appropriate and constants use of contraception methods are under the influence of having sufficient information about these methods and their side-effects.[5] The best way to leave these problems out or to modify them is conducting counseling during the selection of a contraception method.[3] Appropriate counseling given by health services staffs can help to clients for select of the most efficient method and guarantee their achievement to their objectives in family planning and maternal health as well as the client's satisfaction with the quality of these services through making a change in their awareness, skill and attitude toward pregnancy and contraception methods.[678] Therefore, it can be concluded that one of the basic principles to succeed in contraception methods is an appropriate family planning.[9] Previous qualitative research in family planning has introduced numerous obstacles, such as organizational and structural obstacles. Mugisha and Reynolds (2008) reported that organizational and structural factors such as availability of contraception methods, the related equipments and work overload are as effective elements on quality of family planning services.[10]

Baraitser et al. (2003) in their study pointed out to lack of privacy, tiresome environment and unsuitable clients’ waiting room as the obstacles of clients’ participation in receiving family planning services.[11]

Mohammad-Alizadeh et al. (2009) in their investigation on the obstacles in family planning services quality, reported that mismanagement and limitation of time act as the influencing factors.[12] Although qualitative research has detected these obstacles, these obstacles have not been studied with a proper sample size in a quantitative research in Iran. Detection of the most important and efficient obstacles, can speed up the initial steps to delete or modify these obstacles more efficiently and enhance the quality of family planning counseling. On the other hand, comparison of viewpoints in three groups of managers, staffs and clients can show us the possible weakness in family planning counseling. The dissimilarity of these obstacles in viewpoints of the various individuals’ may lead to conflicts in their function either to delete or control these obstacles and eventually, result in failure of family planning counseling. Therefore, in order to improve the quality of present counseling and to access the family planning goals and with regard to the importance of concurrent measurement of these viewpoints, the present study aimed to compare managers’, staffs’ and clients’ viewpoints about organizational and structural obstacles in family planning counseling in health care centers in Isfahan in 2012.

MATERIALS AND METHODS

The present study is comparative descriptive cross-sectional one-step three-group study on 295 subjects including 59 managers, 110 staffs and 126 clients. A total of 20 health-care centers were selected through a lottery to recruit their staffs and clients. Sampling was a census for staffs and convenient random sampling for a group of clients. Inclusion criteria were married women aged 15-49 years who were using one of the contraception methods.

The managers were selected through census sampling from 44 health-care centers as well as managers and family planning experts in provincial health centers and health centers number 1 and 2 in Isfahan.

Data were collected by a researcher made questionnaire including 2 sections. The first section contained questions on managers’, staffs’ and clients’ personal and fertility variables and the second section included a viewpoints survey questionnaire of organizational and structural obstacles in family planning. The viewpoints about organizational and structural obstacles in family planning were investigated by mean obtained score of answering 21 five-point Likert scale questions in the questionnaire of viewpoint survey. The answers were scored as absolutely disagree (Grade 0), disagree (Grade 1), no idea (Grade 2), agree (Grade 3) and absolutely agree (Grade 4). Organizational and structural obstacles were the obstacles such as lack of privacy, inadequate educational equipments and inadequate various supplies of contraceptives in health-care centers [Table 1]. Content validity was used to confirm the validity of the questionnaire, prepared by referring to textbooks and valid articles. Reliability of the questionnaire was confirmed through Cronbach's alpha test (α = 0.91). Data were collected through a self-report questionnaire in two groups of managers and staffs and self-report or questioning in the group of clients. Data were analyzed by descriptive and inferential statistical methods one-way ANOVA through SPSS.

Table 1

Frequency distributions (%) of the responses to viewpoint surrey in managers, staffs and clients based on organizational and structural obstacles

RESULTS

With regard to personal and fertility characteristics of the managers, there were 59 subjects (33 female and 26 male) with a mean age of 43 ± 5.5 years, with managerial experience of an official post for 10 ± 6 years, of whom 79.7% were general physicians and 54.2% had two children. About 49.2% of the managers were relatively satisfied with continuing education programs concerning family planning counseling. With regard to personal and fertility characteristics in the group of staffs, there were 110 subjects with a mean age of 39.7 ± 6.2 years with 13 ± 6.7 years work experience in family planning counseling of whom 54.6% had BS of midwifery and 50.9% had two children. With regard to the staffs’ responses, mean daily number of clients referring to the center to receive counseling was calculated 10 ± 6 and the staffs had spent 10-20 min for each counseling session. Furthermore, 72.7% of the staffs were relatively satisfied with continuing education programs in relation with family planning counseling. With regard to personal and fertility characteristics of the clients, there were 126 subjects with a mean age of 29.7 ± 5.8 years, 88.1% repetitive referrals, of whom 46.8% had education, lower than diploma, 92.1% were housewife and 56.1% had only child. About 41.3% of the clients reported the average time of waiting to receive family planning counseling as 10-20 min and 64.3% reported average length of time for each counseling session less than 10 min. On the other hand, 50.8% were relatively satisfied with the received family planning counseling in health-care centers. The obtained results with regard to subjects’ viewpoints reveal that the mean score of viewpoint about organizational and structural obstacles in family planning counseling in three groups of managers, staffs and clients were 49.60 ± 16.40, 49.50 ± 17.15 and 48.30 ± 13.15 respectively. One-way ANOVA showed no significant difference in comparison of managers’, staffs’ and clients’ viewpoints mean scores with regard to organizational and structural obstacles in family planning counseling (P = 0.677).

As presented in Table 2, based on the obtained scores from organizational and structural obstacles questionnaire and their classification in five sub-groups, most of the managers (40.7%), staffs (48.2%) and clients (56.3%) reported the existence of organizational and structural obstacles in family planning counseling in moderate level.

Table 2

Frequency distribution of viewpoint scores in three groups of managers, staffs and clients in relation with organizational and structural obstacles in family planning counseling

Table 1 shows that the frequency distribution of the responses to questions on organizational and structural obstacles are different in three groups of managers, staffs and clients.

DISCUSSION

In the present study, most of the managers, staffs and clients reported that organizational and structural obstacles act as the obstacle in family planning process in a moderate level. In direction with the obtained results, Akers et al. (2010) stated that there are numerous obstacles in family planning counseling from the side of health providers and health services system.[13]

In the present study, despite the agreed viewpoints of most of the managers and staffs with regard to staffs’ work overload and lack of adequate time for family planning counseling, most of the clients disagreed with this issue. Research in quality of services and family planning centers reported that health providers are busy and this act as a factor for reduction of quality.[1012141516] This difference in viewpoints may be possibly due to the fact that clients did not observe so much services given by staffs to clients in their waiting time to assume they were working busily. Staffs’ work overload from managers’ and staffs’ viewpoints can also be interpreted as spending a lot of time to record data in the files. Therefore, the findings show the necessity of a clients’ appointment management system to relieve daily workload as well as running an electronic system to record the data to speed up provision of services.

Previous researches in relation with quality of family planning services and the quality of the centers providing these services have reported problems such as clients’ problems in receiving family planning services, staffs ignoring the clients and not spending adequate time on them despite having free time,[14] staffs’ inappropriate behavior,[10111415] long waiting time to receive family planning counseling,[17] low interested and motivated staffs,[16] lack of staffs’ commitment in the provision of family planning counseling properly,[18] ignoring clients’ suggestions and desires during counseling[19] and low experience of family planning counselors.[20] In the present study, most of the managers, staffs and clients disagreed with the existence of these obstacles in family planning counseling. Kols and Sherman (1998) stated that clients may pretend being satisfied with the services as a result of pleasing the staffs, fear of missing services in future and cultural reasons.[21] On the other hand, as the present study is quantitative while the studies from which the primary concepts were extracted were qualitative, it can be supposed that these problems also existed in the study population of the present study although most of the clients disagreed with the existence of such obstacles in family planning counseling process. This issue is consistent with the results of qualitative studies. On the other hand, it may reveal the necessity of planning to reduce these problems, even in a low amount.

In the other research on the quality of family planning services and the centers providing these services, reported factors such as inadequate various supplies of contraceptives in the health-care centers and limitations in the provision of some contraception methods despite being selected for the subjects in family planning counseling in all physical conditions for example absence of mense to insertion of Intrauterine Devices (IUD),[10] lack of educational facilities[222324] and privacy[2526] as the factors to reduce the quality of services. These factors were the obstacles in conducting counseling from the viewpoint of most of the managers, staffs and clients in the present study. Therefore, it is essential to modify the shortage of various supplies of contraceptives in health centers and educate health providers, prepare educational facilities and educate the staffs to use these facilities during family planning counseling as well as to provide a room for family planning counseling in health-care centers to respect clients’ privacy.

In the present study, opposite to viewpoints of most of the staffs and managers, most of the clients preferred to refer to private health centers. It possibly shows that the clients accepted to tolerate higher costs to receive higher quality care in those centers. As Mohammad-Alizadeh et al. (2009) reported that clients prefer to refer to private centers due to low quality services of governmental centers.[12] Therefore, service providers should investigate the cause that makes the clients leave out of charge services in governmental centers and refer to other centers.

With regard to viewpoints of most of managers concerning lack of sufficient information provision in the centers, most of the staffs and clients denied the existence of this problem as an efficient obstacle in family planning counseling. Mohammad-Alizadeh et al. (2007) introduced this factor as a reducing element for quality of family planning services.[23] It can be argued that this response from clients is as a result of their lack of awareness form the amount of word “adequacy” in level of received information. On the other hand, the staffs may have denied this obstacle, due to supporting their position and their other colleagues’ and existence of their personal beliefs in the concept of adequacy of information provision. However, managers’ agreement with this issue can be due to factors such as lack of their trust in adequacy of information provided by the staffs, lack of their proper supervision on the manner of staffs’ services and the managers’ belief in staffs’ work overload and their disability to provide the information adequately. It seems that for detection of these obstacles more precisely, conducting more studies in relation with the evaluation of level and quality of transferred information to clients is essential.

Baraitser et al. (2003) argued that teenage clients were dissatisfied with the suitability of the waiting room in their family planning counseling.[11] In addition, with regard to negative viewpoints of most of the managers and clients concerning unsuitability of the waiting room, most of the staffs accepted the existence of such obstacle in family planning counseling, which can be as a result of clients’ low expectation and preservation of managers’ prestige in position of the authorities to supervise the appearance and physical atmosphere of the centers. It is notable that the staffs as the persons attending the centers more than the managers and clients may detect problems in the centers, which need more attention.

The other finding is agreement of the managers and the staffs on the fact that the staffs care making files for clients’ to respond to their problems and not provision of sexual counseling related to preconception methods, for which most of the clients’ disagreed. In qualitative study of Mohammad-Alizadeh et al. (2009) and Mohammad-Alizadeh et al. (2008),[15] the clients referring to health centers complained of ignoring their sexual problems related to contraception methods and claimed that the staffs pay more attention to completing their medical file related to their problems. The clients’ dissatisfaction may be related to lack of clients’ expectations and respect to health providers, fear of responses to receive the services and their outcomes, not feeling comfortable to talk in relation with sexual subjects. On the other hand, it should be noted that acceptance of most of the managers, staffs and a number of clients concerning these obstacles revealed the existence of such problems in the health system and necessitates planning to solve these problems through making electronic clients’ files to provide them with the needed care and reduce waste of time and staffs’ concern for recording patients manually in order to have more time and peace to provide clients with services.

In the present study, most of the staffs, opposite to other two groups, agreed that Forbid to attendance of men in counseling sessions is an obstacle in family planning counseling process. Mohammad-Alizadeh et al. (2008)[15] reported the same limitation for men to attend the session during receiving family planning services. The reason for this difference is possibly in their viewpoint in not experiencing their spouses’ attendance due to working shift of the centers (just mornings). Therefore, in order to involve men in family planning counseling more, these problems should be solved through planning and educating the staffs to let women attend with their spouses in family planning counseling as the staffs accepted to have this obstacle in health-care centers.

CONCLUSION

In general, the results of the study showed that the mean viewpoint score of the managers, employees, and clients in the field of organizational and structural obstacles have been different. The findings showed that organizational and structural factors are not considered so important by the clients as the health system planners believe. More investigation and administration of a need assessment are essential to detect the existing basic clients’ concerns through group discussion sessions with the presence of three major components in services provision – receive system and all problems should not be related just to the health system.