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Journal of the Academy of Hospital Administration

Women With Reproductive Disorders and Quality of Service

Author(s): S. Chhabbra*, P.V. Shivkumar**, S. Mishra***

Vol. 17, No. 2 (2005-01 - 2005-12)

Key Words:Consumers, Providers, Satisfaction, Dissatisfaction, Quality Service

Key Messages:

  • Cost of surgery varies from discipline to discipline with Oncosurgery being most expensive
  • Medical equipment contribute to significant capital costs in OT

Abstract

The present study was aimed at finding relevant information for improving the quality of services provided to women hospitalized for reproductive disorders. The objective were to ascertain the perceptions and expectations of the women consumers and their relatives; difficulties of providers, the suggestions of consumers as well as providers for quality services within resource constraints. In this cross sectional study, one thousand women with reproductive health disorders, admitted to a tertiary hospital were interviewed. For each study subject, one relative, one nurse, a junior doctor and a senior doctor involved in her care interviewed making a total of 5 interviews per case.

It was observed that, over all majority of the women were satisfied (62.4% satisfied vs 37.6% dissatisfied) with the services, More women from upper and middle socioeconomic class were satisfied compared to lower class, More of rural women were dissatisfied compared to urban, No significant difference in numbers of satisfied and dissatisfied was found in relation to distance from the health facility.

If the health services have to be used effectively, providers need to know the expectations and preferences of the users, it is also important for the consumers to know the resource constraints within which schemes are being provided. Nontechnical aspects of health care play very important role in satisfaction of providers and consumers.

Introduction:

Quality care is the right of health seekers but has been neglected till recent times. It is a mutually beneficial process in which consumers and providers, both play major roles. The health workers and their environment must be closer to providing the quality service that fulfills the professional goals of health workers and is in accordance with health care needs of the clients (1). Providers perceive their satisfaction at technicalities and do not visualize the user's sufferings due to various other reasons including mental, physical and financial. Further, quality, access and cost are interrelated program elements, and change in one effect the others. Given their finite resources, programs any face difficult choices as they attempt to find the appropriate balance. Ideally, decisions about quality should be after dialogue among policymakers, providers and clients. Each program has to decide what standard of quality is appropriate to apply considering situations, resources, the need, and the perception of the people, it is meant to serve.

The present study is an attempt to know the lacunae and positive aspects of the services provided to the women seeking services for reproductive health disorders.

MATERIAL & METHODS

The present prospective study was done at a rural healthcare institute over a period of 6 months. The study population comprised of 1000 women admitted for gynaecological disorders in the hospital. They were interviewed by a social worker assigned this job with the help of a predesigned (structured) and pretested proforma. Interviews were conducted between 9am to 6pm everyday except holidays. Study subject, one of her relatives, who was attending to her, one nurse, concerned junior doctor and senior doctor who had managed the case as per their duties were interviewed making a total of five interviews per case. As the patients were admitted over a period of six months and the care givers were same throughout the study period, the total number of nurses was 40, and senior and junior doctors 30. The study subjects were asked about their satisfaction & dissatisfaction of the services provided, where as care providers were asked about reason for their satisfaction/dissatisfaction including suggestion for improving care delivery.

OBSERVATIONS

Out of 1000 women interviewed, only 22.20% were urban where as majority (77.80) were rural. Only (4.6%) belonged to upper class, 58.6% upper middle class, 20.9% lower middle and 15.9% of lower class, as shown in table I. Age distribution showed that only 1.2% women were teenagers, 29.4% between 20-34 years, 33.9% 35-49 years and 35.5% were of 50 years of more. Majority of them (86.2%) were presently married & the rest were unmarried or widows. This was a cross section representing cases seeking obstrical gynaelogical services in day to day life. Over all, 62.4% women were satisfied with the services they were receiving but 37.6% were not. More women belonging to upper & middle socioeconomic status were satisfied. Satisfaction was present in 37.9% rural and 40.1% urban cases.

It was found that 37.4% women had been hospitalized for abnormal uterine bleeding out of which 43.3% were satisfied & rest were dissatisfied, 22.4% women were admitted with lower abdominal pain during menstruation or intercourse out of which majority (63.4%) were satisfied as evident from Table II.

Many women were satisfied because of satisfactory treatment with availability of all the specialists under one roof (88.9%) and also because prior to major surgery thorough work up including biopsies (31.6%) etc were done to authenticate the diagnosis (38.6%); no empirical treatment was given and appropriate therapy was being provided without complications (76.8%) they also were satisfied because insurance schemes, which the Institute has, helped them in getting economical treatment.

TABLE-I: Age, Socioeconomic Status & Women's Satisfaction/Dissatisfaction

Age Socioeconomic Status* Satisfaction# Dissatisfaction# Total Grand Total
No. % No. % No. % No. %
< 19 Upper 2 16.7 1 8.3 3 25.0 12 1.2
Upper Middle 2 16.7 -   2 16.7    
Middle 2 16.7 -   2 16.7    
Lower Middle 2 16.7 -   2 16.7    
Lower 2 16.7 -   2 16.7    
Sub-Total   10 1.28 2 0.53 12 1.2    
20-35 Upper 16 5.4 2 0.7 18 6.1    
Upper Middle 65 22.1 11 3.7 76 25.9    
Middle 75 25.5 19 6.5 94 32.0 294 29.4
Lower Middle 42 14.3 17 5.8 59 20.1    
Lower 37 12.6 10 3.4 47 15.9    
Sub-Total   235 37.6 59 15.6 294 29.4    
>35-45 Upper 8 2.4 2 0.6 10 2.9    
Upper Middle 49 14.5 58 17.1 107 31.6    
Middle 31 9.1 50 14.7 81 23.9 339 33.9
Lower Middle 29 8.6 49 14.5 78 23.0    
Lower 22 12.0 41 12.1 63 18.6    
Sub-Total   139 22.2 200 53.1 339 33.9    
>45 Upper 12 3.4 3 0.8 15 14.2    
Upper Middle 88 24.8 35 9.9 123 34.7    
Middle 72 20 29 8.2 101 28.5 355 35.5
Lower Middle 45 20.7 25 7.0 70 19.7    
Lower 23 6.5 23 6.4 46 12.9    
Total   624 62.4 376 37.6 1000 100 1000 100%

*Socioeconomic status as per Kuppuswami's classification
# Satisfaction and dissatisfaction:- both number and % are calculated within respective age groups

TABLE-II: Symptoms & Satisfaction/Dissatisfaction

Sr. no Symptoms* Age Group
  < 19 20-34 >35-44 >45  
Satis Dissatis Satis Dissatis Satis Dissatis Satis Dissatis  
Abnormal uterine bleeding 3 1 98 38 60 70 80 24 374
Lower abdominal pain (menstruation and with Intercourse) 3 - 47 9 28 43 65 29 224
Urinary Complaints - - - - 7 10 10 9 36
Lump in abdomen 2 - 26 9 11 23 20 9 100
Vaginal discharge 2 1 25 - 16 21 25 20 110
Something coming out - - 6 1 7 21 30 12 77
No Issue - - 33 2 10 12 10 12 79
Total 10 2 235 59 139 200 240 115 1000
*Many respondents had multiple complaint, but their chief complaint was taken into coordinations.

 

TABLE-III: Reasons for Consumers Satisfaction/Dissatisfaction

Satisfaction Dissatisfaction
(A) Nontechnical (A) Nontechnical
  No.* %   No.* %
Equity 595 59.5 No Information of time bound insurance 216 21.6
Insurance Schemes 599 59.9 No rest room 288 28.8
Hot water 266 26.6 Rude behaviour of security guards attendants 196 19.6
Senior doctor's sympathetic attiude 669 66.9 Restaurant closed after 8 p.m 288 28.8
Facility for food 562 56.2 Bills not cleared fast 166 16.6
(B) Technical (B) Technical
  No.* %   No.* %
Proper examination & investigation 386 38.6 Longer stay between minor and major surgery 268 26.8
Minor surgery before major post operative issues 316 31.6 Investigation money 208 20.8
Presurgical speciality consultation X-ray & U.S.G. etc. 482 48.2 Inadequate ifnormation of Medications 296 29.6
Emergency blood 599 59.9 Ambulance not available arrangement 301 30.1
Consultants round every day 888 88.8 Prescription not in local language 108 10.8
Specialities under one roof 889 88.9      
Appropriate therapy 768 76.8 No information of cost of operation 302 30.2
Easy access to senior doctor 606 60.6      

However a little over a third (38%) of the consumers were dissatisfied because of long gaps between admission & curative therapy (mainly for major surgery) for various reasons causing financial and social difficulties. About a quarter (26%) women also complained that immediate attention was given to maternity cases but not to them. Women with infertility stated that they have been waiting every month to conceive and are being given a long list of investigations (20.8%) which are time consuming and not available under one roof. Nonavailability of ambulance in emergency (30.1%) boarding & lodging facilities near the hospital were other reasons of dissatisfaction. Some women were dissatisfied because senior doctors themselves did not explain in details regarding operation, postoperative problems and medication after discharge (29.6%) etc. (Table III) Relatives were satisfied mainly because they thought the therapy was satisfactory and economical but were dissatisfied due to non-availability of boarding & lodging facility near the institute. They were also dissatisfied because of the behavior of security guards & helpers in the wards. Delay in the curative treatment, inadequate information of insurance schemes before admission, delay in preparation of discharge slips were other reasons for dissatisfaction as shown in (Table III) Providers were satisfied because of the consumers' receptive behavior availability of day to day material for patient care especially surgical because their services were appreciated by users. They were dissatisfied because partial or complete waiving off the bills was again and again requested by patients' relatives and also because some relatives did not arrange material needed for surgery well in time and also some left the patients in the hospital for days together, in as evidence (Table IV).

TABLE-IV: Reasons for Providers Satisfaction Dissatisfaction

Category No of Satisfaction No of Responses* Dissatisfaction No of Responses*
Nurses Timely arrangement of medicines blood 806 Language 306
Timely bill payment 382 Relatives insist for bill off 201
Relatives receptive, helping 496 Threaten by senior doctor's names 161
Appreciate hospital staff 608 Insist on early discharge Report on day other than own Doctor's day. 106
Receptive accommodative 388 Abscond 306
    Relatives leave patients with complications 116
    Visit other than visiting hours 118
    Want to stay due to family problems causing unnecessary bed occupancy 228
    Long duty hours lead to lack of attention 306
Junior doctors Aware, listen about complications 496 Insist for early discharge 206
Arrange medicines fast 776 Abscond 308
Arrange medicines, blood fast 701 No attention to nutrition, hygiene 236
Appreciate treatment 689 Patients abscond 129
    Insist on discharge even if hospitalization 208
Senior doctors Relatives receptive, take care of patients post operatively 366 Too much expectation regarding explaining each & every aspect related to surgery. 240

*The total number does not add upto 1000, due to multiple responses.

When the consumers were asked about their suggestions for improving quality of services, most of them desired that staff must be more sympathetic, arrangements for the day to day needs' including facilities for stay of relatives in or near the hospital complex, and therapies need to be quick and cheaper. They also desired that there should be more involvement of senior doctors during discharge for explaining about medication, future problems etc. They also suggested Original Article that there should be better communication between nurses and junior doctors to prevent inconvenience to patients & relatives. Another suggestion was separate area for billing, (Table V). Providers had also suggested to have separate cell for awareness, education & counseling women about hygiene, diet, the problems of surgery, after effects etc.

TABLE-V: Consumers/Providers Suggestions for Better Care

Consumers Suggestions for Better Care
Category Suggestion No. of Response*
Subjects & Relatives Toilets, shelter cold water 489
Attempts change behavior of staff 382
24hrs restaurant 556
Longer duration of insurance card 777
Discharge if waiting time more 386
Credit basis medicine 539
Explain post-operative care to relative 382
Proper explanation of medicines by senior doctors 487
Prior explanation of post operative problems 238
Prescription on discharge card in local language 231
More staff 386
Increased duration of visiting hours 286
Providers
Nurses Translator must for consumers with language problems 678
Early discharge 339
Early investigation result 456  
Diet & Hygiene advice in separate cell 446
Explain post operative problems prior to surgery 391
Junior & Senior Doctors Provide reports before discharge 339
Explain nutrition & hygiene through live demonstration 28
Timely arrangement of medicine & blood 561
Relatives must come prepared financially 688
Patients should not leave hospital for hours together 231
Separate billing systems 881
More staff 906
Less working hours of doctors, nurses, helpers 779
Less working hours of post graduates 780
Relatives to be present at time of discharge to avoid repeated explanations 330

*The total number does not add upto 1000, due to multiple responses.

DISCUSSION

Reproductive health disorders are quite stressful and the fear of their implications including cost of care creates further strain on women and their families. In the present study, more women with menstrual disorders were dissatisfied, as irregular heavy menstruation made them physically as well mentally sick and delay in the therapy resulted in further stress. It was obvious that many health seekers had no knowledge of details of disorders, their implications, the importance of investigations and pre surgery preparation to prevent complications. They did not understand the importance of dilatation and curettage or cervical biopsy before hysterectomy and felt that doctors delay curative therapy unnecessarily. In the study done by Bessinger and Bertrand in 2001, (2) researchers had measured the quality of care by quick investigation of quality through client exit interviews. They had studied satisfaction of clients for demonstrating good counseling skills (composite) by providers, assuring client confidentiality, their reproductive intentions, treat the clients with respect/courtesy, infection control procedures etc, Clients were satisfied that information was kept confidential, facilities such as basic items needed through service delivery points, privacy, supervisor visits, adequate storage of medicines, acceptable waiting time etc. were provided. Observations and client exit interviews provide information for many indicators. However, while some programs may opt for one instrument over the other because of resource constraints, the combination provides a fuller assessment of quality of care.

Some women who had abnormal uterine bleeding were satisfied because ultrasonography (USG) was also done with the notion that the doctor could see the disease clearly to provide right treatment. Pain is easy to treat than abnormal bleeding, so probably easy relief is the cause of satisfaction/ dissafisfaction. Women with infertility were dissatisfied due to long set of investigations and finances for various procedures. Their dissatisfaction is obviously due to the socio cultural milieu in the country. Infertile women need more of counseling before therapy, as reproduction is an intricate process and many things need to be in place for a pregnancy to occur. Empirical therapy may do more harm than good. Patients and relatives had suggested that there should be more involvement of senior doctors before discharge to explain all the details and after effects etc. While this is ideal, it is most of the times difficult to implement in a busy medical institute with responsibility of clinical care as well as many other responsibilities of senior clinicians. Unless the ratios change this seems a difficult proposition, however all attempts need to be made.

Some women who were operated were dissatisfied a some important issues had not been discussed in depth preoperatively and later it was known that they had some misconceptions. They came to know the implications when they themselves asked the questions and were not informed earlier. One of the important issues was no information regarding sexual relations after surgery. A study by Stead et al in 1999 (3) had revealed that in United Kingdom 83 hysterectomised women who were sexually active suffered from problems of dyspareunia or had no intercourse due to the fear of pain and damage to operation. It is essential to do counseling of women pre as well as post operatively.

CONCLUSION

One needs to look in the availability of quality health care keeping in mind social cultural milieu and the perceptions of health seekers. Further, definition of quality differs depending on the socio cultural perceptions, awareness of health seekers and providers and resources. Present study was an attempt to know the positive aspects and lacunae in health care so as to have information for planning health care which goes parallel to consumers expectations and effective services with resource constraints.

REFERENCES

  1. Kwast BE. Quality of care in reproductive health programmes: Monitoring and evaluation of quality improvement; Midwifery 1998;14:199-206
  2. Bessinger RE, Bertrand JT, Monitoring quality of care in family planning programs: A comparison of observation and client exit interviews. International family planning perspectives 2001,27(2): 63-70.
  3. Stead M.L., Crocombe W.D, Fallowfield L.J.et al.. Sexual activity questionnaires in clinical trials: Acceptability to patients with gynaecological disorders Br.J. Obstet & Gynaecol 1999;106;1,50-54.

* Director, Professor &amp; Head, Department of Obsterics &amp; Gynaecology, MGIMS, Sevagram, Wardha, Maharashtra
** Reader, Department of Obsterics &amp; Gynaecology, MGIMS, Sevagram, Wardha, Maharashtra
*** Social Worker, Department of Obsterics &amp; Gynaecology, MGIMS, Sevagram, Wardha, Maharashtra

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