A comparative study of the attitudes of managers, employees and clients in the field of social barriers of family planning counseling in health care centers of Isfahan in 2012.

BACKGROUND: Appropriate family planning counseling for informed choice, the right and responsible use of contraceptive methods is very important. Various barriers such as social barriers can have the effect on family planning counseling. In addition, investigation of those barriers from the perspective of managers, staff and clients, who are major members in health care system, has great importance. The present study was conducted with the goal of comparing managers', employees', and clients' viewpoints about social barriers 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 employees, and 126 clients in medical health care centers in Isfahan in 2012. Managers and employees were selected by census sampling and the clients were recruited through convenient random sampling. The data 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 significant difference between mean scores of viewpoints in three groups of managers, employees, and clients concerning social barriers in family planning counseling (P = 0.001). In addition, most of the managers and employees reported social barriers as the barriers in process of family planning in a large level and clients reported it in moderate level.
CONCLUSION: The results express the necessity of health services managers' planning to modify or delete social barriers, especially the agreed barriers from the viewpoint of managers and employees that effect on family planning counseling and quality of service provided by them.

INTRODUCTION

Statistics show that per minute around the world, 380 women become pregnant, and 190 of them women have inadvertent or unplanned pregnancies[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 promotion of maternal health, enhancement of women's social position and overall social economic development.[23] Choosing the best method to prevent pregnancy is a major concern for worry couples about unwanted pregnancy.[4] On the other hand, appropriate and constant use of contraception methods is under the influence of having sufficient information about these methods and their side effects.[5] Hosseni et al. have said that the major causes of unexpected pregnancies are the failure in contraception methods and lack of selecting an efficient contraception method.[6] The best way to leave these problems out or to modify them is conducting counseling during selection of a contraception method.[3] Appropriate counseling given by health services employee can help clients for selecting 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,[789] Therefore, it can be concluded that one of the basic principles to succeed in contraception methods is an appropriate family planning.[10] There is no doubt that proper counseling is one of the important factors in achieving the objectives for family planning programs such as reducing unwanted pregnancies. According to the available statistics of the rate of unintended pregnancies from the new monitoring and assessment system of Iran (2005), evaluation of potential barriers involved in proper consultation for family planning is very necessary and worthwhile.

Previous qualitative research in family planning has introduced numerous barriers such as social barriers. Mugisha and Reynolds in a qualitative study examined the viewpoints of the providers about the effective social factors barriers on the quality of family planning services such as lack of political supports from family planning and lack of male participation in the family planning programs.[11] Campbell et al. (2006) also examined the barriers to fertility regulation in women. They reported about factors such as influence of religious and cultural traditions, choosing the proper contraceptive method, social barriers, having the wrong information, lack of awareness, and financial costs of the client to obtain methods of contraception.[12]

Although qualitative research has detected these barriers, these barriers have not been studied with a proper sample size in a quantitative research in Iran. Detection of the most important and efficient barriers can speed up the initial steps to delete or modify these barriers more efficiently, and enhance the quality of family planning counseling. On the other hand, comparison of viewpoints in three groups of managers, employees, and clients can show us the possible weakness in family planning counseling. The dissimilarity of these barriers in viewpoints of the various individuals’ may lead to conflicts in their function either to delete or control these barriers 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’, employees’, and clients’ viewpoints about social barriers 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 employee, and 126 clients. Total of 20 health care centers were selected through lottery to recruit their employee and clients. Sampling was census for employee and convenient random sampling for 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 the managers and family planning experts in provincial health centers and health centers number 1 and 2 in Isfahan.

The data were collected by a researcher made questionnaire including two sections. The first section contained questions on managers’, employees’, and clients’ personal and fertility variables, and the second section included a viewpoints survey questionnaire of social barriers in family planning. The viewpoints about social barriers in family planning were investigated by mean of obtained score of answering 9 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). Social barriers were the barriers like lack of privacy, inadequate educational equipments, and inadequate various supplies of contraceptives in health care centers [Table 2]. 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. The data were collected through a self report questionnaire in two groups of managers and employees, and self report or questioning in group of the clients. The data were analyzed by descriptive and inferential statistical methods (One way ANOVA) through SPSS 19.

Table 2

Frequency distributions (%) of the responses to viewpoint surrey in managers, employee and clients based on social barriers

Findings

With regard to personal and fertility characteristics of the managers, there were 59 subjects (33 female and 26 male) with 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. The majority of managers (39 percent) had passed less than five courses in the field of family planning counseling that 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 group of employees, there were 110 subjects with 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 employees’ responses, mean daily number of clients referring to the center to receive health primary care and family planning counseling was calculated and 17 ±8 and 10 ± 6, respectively. The majority of employees (34.5 percent) had passed 5-10 courses in the field of family planning counseling that 72.7% of the employees 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 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. Their desired average number of children was 2.3. 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 mean score of viewpoint about social barriers in family planning counseling in three groups of managers, employees, and clients were 63± 12.4, 68.1 ± 13.6, and 46.1± 11.30, respectively. Thus, there was the highest average viewpoint score in the employees group and the lowest in the client group. In relation to measure the mean viewpoint score, one-way ANOVA test showed that, the average viewpoint score of the three groups varied in terms of social barriers (P < 0.001). LSD post hoc test indicated that in this field, there was a significant difference in the mean viewpoint score of the employees with managers (P = 0.001) and clients (P < 0.001) and managers and clients (P < 0.001). In other words, the clients thought the social barriers less than the other two groups as a barrier for family planning counseling process.

As presented in Table 1, based on the obtained scores from social barriers questionnaire and their classification in five sub-groups that the majority of managers (49.2%), employees (53.6%) as a large extent and the majority of clients (53.2%) as the modest reported about societal barriers on family planning counseling [Table 1]. Table 2 shows that the frequency distribution of the responses to questions on social barriers are different in three groups of managers, employees, and clients.

Table 1

Frequency distribution (%) of viewpoint scores in three groups of managers, employee and clients in relation with social barriers in family planning counseling

DISCUSSION

In general, the results of the study showed that the mean viewpoint score of the managers, employees, and clients in the field of social barriers have been different. In other words, the majority of managers and employees considered the social barriers to high levels and the majority of clients as the modest effective on family planning counseling. One of the most important reasons, despite the efforts of the population of managers in reducing unwanted pregnancies has been the usage of ineffective methods of prevention. There was the same difference in the viewpoints of the service providers and the service recipient in the healthcare system. Mugisha and Reynolds (2008) during their interviews with employees and managers of family planning programs have found that social environment had affected on the quality of provided cares in different ways, like that the employees at the time of offering the contraceptive method to the clients were considered the couple's relationship and their ability to pay for specific methods.[11] Political supports for family planning and the data transfers from friends were also effective on the choice of contraceptive method. In this study, most of employees were agreed that the clients were not able to afford the provision of specific methods from the pharmacies such as pills and particular condoms. However, most of the managers had a neutral opinion. Meanwhile, the greatest number of clients had the opposite viewpoint. In the study of Majlesi, Moghadam and Shariat (2011), the unawareness of the clients to the objectives and benefits of family planning counseling, lack of importance to counseling by the clients and the differences between them have been identified as the influencing factors on the quality of family planning services.[13] In the current study, most of managers and employees were agreed with the topics such as changing the family planning policy, effectiveness of the comments from relatives and friends to the choice of contraceptive method, lack of men participation to attend family planning counseling, unawareness of the clients about the objectives and benefits of family planning counseling, lack of importance to the advices and being indifferent by the clients. However, most of the clients have been hostile with the impact of these issues on choosing the method of contraception. In this regard, Kadia and coworkers (2005) have reported that the men were tended to participate in the family planning discussion, but they did not have enough knowledge in this field.[14] In line with the results of Kohan and colleagues study,[15] the clients in the present study during their conversation with the researcher have referred to this issue that their spouses are interested in participating in the family planning counseling but their business and unsuitable working times did not allow them to attend in the health – medical centers. In this study, it has been evident about the counterpoint of employees and managers regarding the men participation in family planning programs. Creel and coworkers (2002) in their systematic review have expressed that social level, clients’ experiences, fear of discrimination and lack of respect for them by the providers have shaped their behavior in the field of family planning and reproductive health.[16] They believed that in order to provide appropriate service quality, the providers should understand the needs, concerns and attitudes of the clients and respect them. Anoosheh and co-workers (2009) in checking the communication barriers have pointed to different social levels in the field of nurse-patient relationship.[17] In this study, in connection with the dispute at the social level between the parties in family planning counseling, most of the managers and clients had the opposite viewpoints and most of the employees were agreed. The important point is that in order to establish a helpful connection and counseling, the council should not pay attention to the difference at the social level. However, it exists in the reality. The council should try that in dealing with various clients; keep himself/herself at the level of the client. Due to this fact that the maximum number of employees in this study acted as the first line in providing counseling family planning, it is necessary to study the attention to this field and to the health care delivery system. In this study, most of the managers, employees, and clients were agreed about the effectiveness of private doctors’ advices on the thoughts of the referrals in relation to the quality of family planning services in the public health care centers for counseling on family planning. The study of Mohammad Alizadeh (2009) has referred this issue too.[18] Therefore, proper planning is required to be done in this regard for coordination with the given advices in public and private centers in the field of family planning services. In this study, most of managers and employees, despite the legal prohibitions to use some methods of contraception such as requiring written consent of the spouse for tubal ligation, were agreed and most of the clients were opposed. In the study of Hayes (2010), it has been pointed out that the females for tubal ligation as a method of contraception required for showing the written consents of their spouses and this issue could be a limiting factor to use this method for those who were wiling in choosing this method consciously and independently. However, under the pressure from their husbands and especially those who wanted more children were not able to practice their decision.[19] The cause of this opposite view in the clients of this study could be due to have at least one child and Desire to get pregnant again in the future. In the current study and in the context of neglecting of the authorities about having better terms for family planning counseling, most of the managers had no idea. Most of the employees were agreed and most of the clients have had the opposite issue. In the study of Mugisha and Reynolds (2008), the family planning providers had expressed about this obstacle in the process of providing family planning services as a factor in reducing the quality of services.[11] Based on the results of this research, 50% of the clients had a satisfactory state from family planning counseling. The findings showed that 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, Thus, it should not be attributed all of the problems and issues of family planning counseling only to the client group and their social factors associated with them.