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Indian Journal of Community Medicine

A Qualitative Analysis of Maternal and Child Health Services ofr an Urban Health Care Centre, by Assessing Client Perception in terms of awareness, Satisfactioin and Service Utilization

Author(s): Bratati Banerjee

Vol. 28, No. 4 (2003-10 - 2003-12)

Deptt. of Public Health Administration,
All India Institute of Hygiene and Public Health, 110, Chittaranjan Avenue Kolkata - 700 073

Abstract:

Research questions:

  1. Are the beneficiaries/clients aware about MCH services rendered by the study centre?
  2. Are they satisfied with the various aspects of the services provided?
  3. Dothey utilizefull services?
  4. Are demographic and socio-cultural determinants barriers to higher levels of perception?

Objectives: To assess the perception of the clients in terms of knowledge, satisfaction and utilization, regarding the MCH services rendered by the centre and to analyse the demographic and socio-cultural barriers to higher levels of perception.

Study design: Cross-sectional, community based study.

Setting: Area servedby the MCHdepartmentof anurban health centre in Kolkata.

Participants: Antenatal and postnatal women and mothers of under five children. Statistical analysis: Scoring methodfor assessing the perception, percentages, Z test ofproportion.

Results: Nearly two third of the sample perceived the services to be excellent or good regarding their awareness, convenience, utilization and satisfaction, 22.5% felt it was satisfactory and 16.0% thought it was poor or very poor. Categorizing them according to age revealed no definite pattern, but younger mothers seemed to be less satisfied. Excellent or good scoring was obtained more for multiparas than nulli/primiparas and significantly more for Muslims than Hindus, housewives than working women and illiterates than literates, least being with those most highly educated. Maximum utilization was found in case of immunization, followed byinvestigations. Utilization was minimum in case of antenatalcare. Of the total sample 62.75% had availed all the services at this centre only.

Conclusion: The MCH services rendered by the centre had succeeded in generating awareness regarding this service, achieving satisfaction andensuring utilization among majority of the studied sample.

Key Words: Client satisfaction, Beneficiaries perception, MCH services utilization

Introduction:

The health of the mother and child constitutes one of the most serious health problems affecting the community, particularly in the developing countries. To alleviate this problem maternal and child health (MCH) services have seen a spectrum of changes dating from antiquity to the most recent development of reproductive and child health programme. But any programme, however relevant its components are, likely to fail unless it succeeds in improving the knowledge and achieving satisfaction of its clients.

Material and Methods:

The major segment of the population served by this centre are slum dwellers. Since there was no previous study on client satisfaction done in the centre, it was assumed, by the theory of probability, that 50% are likely to be satisfied and 50% dissatisfied. The sample size thus calculated, with an allowable error of 10%, was 400. The study subjects comprised of antenatal (AN) and post natal (PN) mothers and mothers of under five (U5) children. To determine the size of the different groups within the sample, approximately 15% of the total population in each group was taken. The number of U5 children was noted from the records and the estimated number of AN and PN mothers at one point of time was calculated from the birth rate and population of the area, during the previous year1. For selecting the sample, the households were used as the sampling units. Multistage sampling was done, one of the four units of the UHC serving the population being selected by simple random sampling technique using lottery method in the first stage and the requisite number of households of the selected unit being identified by systematic random sampling method in the second stage. Data was collected by house visit and interview method using a pre tested, structured schedule with scoring system. The schedule included provision of services, knowledge and utilization by the mothers and their satisfaction regarding various aspects of the services. Several parameters were worked out including service provision, utilization and its outcome and these were compared with the recommended standards'. The total score of each person was determined and, based on this, gradation was done into five grades A to E, being excellent to very poor respectively.

Results:

Table I: Clients' perception categories among the studied sample.

Grade Category Score Subjects (no.) %
Excellent A 17 - 20 114 28.5
Good B 13 - 16 132 33.0
Satisfactory C 9 - 12 91` 22.75
Poor D 5 - 8 44 11.0
Very Poor E 0 - 4 19 4.75
Total     400 100

Clients perception regarding the services was assessed by compiling several factors like awareness, convenience, utilization, opinion arid satisfaction. The ultimate perception was graded into five groups. It was observed that 28.5% of the beneficiaries perceived the services offered by the MCH department and their convenience and utilization to be excellent and only a meagre section of 4.75% as very poor. On clubbing the groups it was seen that 61.5% of the sample i.e. nearly two third, felt the services to be excellent or good, 22.75% felt them satisfactory and 16.0% felt these to be poor or very poor.

Table II: Beneficiaries perception categories according to demographic variables.

  Categories
A
No. %
B
No. %
C
No. %
D
No. %
E
No. %
Total
Age - years
≤20 36 29.5 54 44.3 30 24.6 2 1.6 0 - 122
21 - 25 30 20.9 42 29.4 41 28.7 18 12.6 12 8.4 143
26 - 30 41 35.7 30 26.1 12 10.4 25 21.7 7 6.1 115
31 - 35 7 35.0 6 30.0 7 35.0 0 - 0 - 20
No. of Children
0 - 1 21 9.4 86 38.4 75 33.5 31 13.8 11 4.9 224
2 - 3 78 53.8 39 26.9 13 8.9 12 8.3 3 2.1 145
4 - 5 7 38.9 4 22.2 1 5.6 2 11.1 4 22.2 18
>5 8 61.5 3 23.1 1 7.7 0 - 1 7.7 13
  114 28.5 132 33.0 90 22.5 45 11.25 19 4.75 400

Z (Multipara, Nullipara) = 0.64; p>0.05, Figures in parentheses indicate row wise percentages

When differences in perception were considered the majority of the older mothers felt it was excellent. Variation according to demographic variables it was observed that due to parity revealed excellent grading to be least among the categorization on the basis of age revealed no definite pattern. nulliparous or primiparous women and maximum among But, it could be noticed that majority of the younger mothers multiparous mothers having more than five children, though

i.e. below 25 years of age, felt the services to be good while this was not statistically significant. Qualitative analysis of MCH services 154

Table III: Beneficiaries perception categories according to socio-cultural variables.

  Categories
A
No. %
B
No. %
C
No. %
D
No. %
E
No. %
Total
Religion
Hindu 103 31.3 81 24.6 82 24.9 44 13.4 19 5.8 329
Muslim 11 16.7 48 72.2 6 9.1 1 1.5 0 - 66
Others 0 - 3 60.0 2 40.0 0 - 0 - 5
Education
Ileterate 95 52.2 67 36.8 14 7.7 6 3.3 0 - 182
Primary 11 15.1 23 31.5 24 32.9 12 16.4 3 4.1 73
Middle 6 6.6 33 36.2 38 41.8 7 7.7 7 7.7 91
high School 2 4.8 8 19.0 12 28.6 11 26.2 9 21.4 42
Graduate 0 0 1 8.3 2 16,7 9 75.0 0 - 12
Occupation
housewife 106 30.2 118 33.6 79 22.5 36 10.3 12 3.4 351
Working Woman 8 16.3 14 28.6 11 22.4 9 18.4 7 14.3 49
Total 114 28.5 132 33.0 90 22.5 45 11.25 19 4.75 400

Figures in parentheses indicate row wise percentages.

Perception was also considered according to some socio-cultural variables. It was seen that 55.9% of the Hindu mothers considered the services to be excellent or good, while 89.4% of the Muslim mothers thought so (Z=5.09, p<0.001).

Literacy affected satisfaction in an inverse way. With increasing literacy, satisfaction appeared to be decreasing. Among the illiterate women 52.2% expressed the service to be excellent and a total of 89.0% of this group felt it was either excellent or good. But only 38.5% of the literate mothers felt so (Z=10.33, p<0.001). Housewives appeared to be more satisfied with the service (Z=2.55, p<0.01), as 63.8% in this group felt the service to be excellent or good, while 44.8% of the working women felt so.

Table IV: Utilization of various services provided by the MCH department (n=400).

Services No. %
Antenatal Care 257 64.25
Family Planning 275 68.75
Immunization 331 82.75
Illness 277 69.25
Investigations 282 70.50
All Services 251 62.75

Table IV shows utilization of the different services provided by the MCH department of the UHC. Since the centre is located in the heart of the service area it is utilized often by the slum dwellers. It was observed that most of the people had availed the services of this centre at least once. Side by side, many of them attended other health facilities also. So, in this table 'utilization' denotes attending only this centre, and no other, for the specified services. Maximum utilization was found in case of immunization, followed by investigations. Utilization was minimum in case of AN care. All the services had been availed in this centre only by 62.75% of the sample.

Discussion:

The government MCH strategy focuses on increasing the knowledge and utilization of services by all segments of the population. In the present study, it was observed that nearly two third of the women in the study could be categorized as good or excellent in terms of knowledge, convenience, utilization and satisfaction. Das et al, in their study carried out in Jawan block, observed even though the population under study had two important sources of AN care, the community health centre and rural health training centre, yet ANC coverage and contraceptive use rate were very low2. Another study in Delhi slums revealed that a very high proportion of women had availed of care during pregnancy. Those who had not reported said that they either "did not know" about the services or "did not feel the need" to use them. Awareness ranged from 52 to 82%. Of all the women who had availed the services, only one sixth had taken care throughout pregnancy. The main reason for this low utilization was lack of knowledge about the services offered, which may in turn be attributed to the high level of illiteracy and lower accessibility of these institutions3. In the present study, excellent or good scoring were obtained more for older mothers than younger ones, multiparas than nulli or primiparas, Muslims than Hindus, housewives than working women and illiterates than literates, least being with those most highly educated. In another study conducted in Delhi, to determine the community awareness on child immunization it was observed that the mothers obtained sub-optimal score (47.5 %) on an average and less than a quarter of the mothers had the desirable level of awareness of 80% or more4. Lack of information was the major reason for non immunization in almost two third of the children in another study undertaken in Delhi slums5. Thus low awareness among the clients is one of the major reasons of low utilization of services.

The main deficiency in the perception of the study sample was observed to be low awareness regarding days and time of the availability of specific services and the location of different service outlets within the centre. The main reasons for dissatisfaction of some of the clients is the inconvenient timing and the long waiting time which are common problems in many free service facilities. Though stock position was fairly good in this centre, occasional non-availability of certain medicines also led to dissatisfaction. The satisfied clients, on the other hand, expressed the view that medicines are most often available in this centre. They also said that the centre provides good service, the staff are friendly and show great care, the doctors give good treatment and also sufficient time to attend to them. Studying the service utilization pattern it was observed that antenatal care and immunization were the two services utilized maximally, followed by family planning services. Investigations were often done in other facilities and during illness they mainly sought treatment from private practitioners, probably because this centre does not provide emergency service round the clock.

The present study showed that the MCH services rendered by the centre had succeeded in generating awareness regarding services, achieving satisfaction and ensuring utilization among majority of the studied sample. The low level of perception in the others may be due to influence of certain socio-cultural and demographic factors. A nulli or primiparous mother may not be quite aware about or familiar with the services, while a multiparous mother, having visited the health facility more frequently, becomes more accustomed to it and is, therefore, more satisfied. With increasing education one's expectation increases, which may explain the less satisfaction among the more highly educated. Housewives had more free time and were, therefore, more inclined to use the services and find these convenient and satisfying than working women. Apart from the differences due to these variables, the centre seems to have provided good quality of services so as to have achieved excellent or good level of perception among majority of the beneficiaries served. The deficiency that is still remaining may be overcome by generating awareness among the community by holding mothers' meetings and extensive IEC programmes, inviting opinions and suggestions from the clients and encouraging enhancedcommunityparticipation.

References:

  1. National Child Survival and Safe Motherhood Programme. Training Module, Programme Interventions.MOHFW, GOI, New Delhi,1992.
  2. Das R, Amir A, Nath P. Utilization and coverage of services by women of Jawan block in Aligarh. IJCM 2001; 26(2): 94-100.
  3. Bajaj J. Knowledge and utilization of maternal and child services in Delhi slums. J of Family Welfare 1999; 45(1): 44-52.
  4. Dua A, Sachdev TR, Rasania SK. A study on community awareness on child immunization. IJPH 2000; 44(4): 134-6.
  5. Kar M, Reddaiah VP, Kant S. Primary Immunization status of children in slum areas of South Delhi - The challenge of reaching the urban poor. IJCM 2001; 26(3): 151.4.

Qualitative analysis of MCH services 156 Banerjee B

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