perception of lay people regarding community health care service

Introduction1.1 Background

Bangladesh has made significant progress in recent times in many of its social development indicators particularly in health. This country has made important gains in providing primary health care since the Alma Ata Declaration in 1978. All health indicators show steady gains and the health status of the population has improved as reflected in the significant decrease in infant (42 per 1000 live birth), maternal (2.9 per 100 live birth) and under-five mortality (53.8 per 1000 live birth) rates over the last decades, with a marked increase in life expectancy at birth (60.25years) and achieving a credible record of sustained 90% plus vaccine coverage in routine Expanded Programme of Immunization, (EPI) along with National Immunization Days (NID) since 19951. But some of this progress is uneven and there still exists inequalities between different groups and geographical regions. The frequency of field workers visit per household could not adequately meet the need of a family for healthcare, especially reproductive healthcare. Community clinics would replace labor intensive and costly health care services with cost-effective extensive health and family planning services at one location2.The Alma Ata declaration emphatically embraces community participation in health care and stresses the links between health and other sectors of society. As far as health care delivery are concerned, the key issues are access and affordability.3 Although the declaration underlines the importance of improving the efficiency of service delivery and performance to recover costs, it does not mention quality, let alone provide any guidance of how the quality of primary health care could be achieved. Although some increase in the utilization of modem health care is noted, researches from Ghana, Burkina, and Mali4,5 shows that the availability of primary health care in and of itself does not ensure its utilization.The establishment of community clinics (CC) is based on the experience of a pilot project at Abhaynagar in Jessore and Mirersarai in Chittagong. The group exercise at Mirersarai in Chittagong demonstrated that 71% and 67%, respectively, of the existing outreach sites may be phased out. The participants from Mirersarai emphasize that even the female clients are able to reach community clinic located within 10-15 minutes walking distance. In the workshop at Abhoynagar it is seen that 46% of the existing outreach sites might be phased out.6The delivery of primary health care in Bangladesh has been taking a remarkably new shape through establishment of 18000 community clinics, the one stop service delivery for every six thousand populations.

The Health and Population Sector Programme (HPSP) 1998-2003, envisioned a client- centered and financially sustainable system to deliver high-quality essential services to the population, specially to the vulnerable group, i.e. women, children, and the poor. The package is designed to improve the health status of families through comprehensive measures, meeting required standards of quality, and making it available at one single service-delivery site to ensure reduced production costs and the optimal use of resources. At the grassroots or community level, this new service-delivery model, warrants a shift in approach from the home-visitation and makeshift the centres (satellite clinics/EPI outreach sites) to the community clinic-based service-delivery plus limited home visits. This indicates that the existing outreach/satellite clinics and the domiciliary services need to be phased out gradually in the reorganized service-delivery plan. The community clinics will be the only major service-delivery outlet at the grass-root level to provide basic health and family-planning services. Nevertheless, limited home visits by the community clinic providers will still be continued as a back up to prevent dropout of critical services and to provide services for population with limited access.

The study of consumer preferences shows that people in Bangladesh wants one stop services.7 Therefore the government has decided to re-organize services by unifying health and family planning services at upazilla level and below and decides to provide services in a three-tiered fixed facility based one stop delivery system, with the upazilla health complex at the upazilla level, the union health and family welfare center at the union level, and the community clinics at the ward or village level. The union health and family welfare centers and upazilla health complex have complementary functions serving as the facilities for referral and support for the community clinics of the respective unions and upazila. The decision of community clinic establishment for every six thousand population at village or ward levels is to provide Essential Service Package (ESP) to the rural people, particularly the poor at free of cost, in a consistent location designed for easy access at the time of need. OneHealth Assistant (HA) and one Family Welfare Assistant (FWA) have been posted in each community clinic to provide health and family planning services from 9 am to 4 pm on all working days. A doctor has been assigned to supervise the activities of each community clinic. The community clinics are supplied with 23 essential drugs to treat common illness such as fever, abdominal pain, diarrhea, cold and cough along with family planning activities and immunization services.Government constructs community clinics on donated land by the community people and its management is supposed to be given to a committee named as community group, consisting 9 to 11 members taken from the local community and having representatives from villagers, including three women, poor landless people.8 The members of the committee will elect or nominate one among them as chairman and the Union Parishad chairman will work as ex-officio, chief patron and supervisor.The utilization of a health care system, public or private, formal or informal may depend on socio-demographic factors, social structures, level of education, cultural beliefs and practices, gender discrimination, status of woman, economic and political systems, physical and financial accessibility environmental conditions and disease pattern and health care system itself.9-12 Studies uncover that severe deficiencies in existing primary health care facilities are related to diagnosis, treatment, and counseling of patients as well as in the supervision of health workers for the following primary care activities: Growth monitoring and promotion, immunization, case management for malaria, diarrhea and acute respiratory infections.13There are not so many studies on community clinic particularly on its utilization. Although the study under Health Systems Development Programme funded by World Health Organization on Assessment of the community clinics: Effects on service delivery, quality and utilization of services in 2002 was extensive but it was too early to see the utilization of services as because many community clinic were yet to be commissioned then and health personnel were not posted everywhere. Therefore, studies on utilization of primary health care services in developing countries are considered here. The concept of community clinic, as a part of reorganizing the health care delivery system in developing countries like Bangladesh is to ensure the delivery of initial services of the Essential Service Package (ESP) to the vulnerable populations including women, children and poor.A variety of factors have been identified as the leading causes of poor utilization of primary health care services including poor socio-economic status, lack of physical accessibility, cultural beliefs and perceptions, low literacy level of mothers and house heads, large family size etc. Review of global literature suggests that all these factors can be classified into following classes cultural and socio-demographic factors, womens autonomy, economic conditions, physical and financial accessibility, and disease pattern and health service issues.

Household surveys revealed that the perceived low quality of health care was one of the main reasons why people did not attend primary health care services in cases of illness.14, 15 Client perceived quality of services and confidence in the health care provider affect the health service utilization inputs, which could be assessed with ease and at low cost, were frequently used as proxies for quality. Such input indicators included the presence of drugs in health centers, staffing, and the availability of electricity or running water. The high use of govt. health care facilities is attributed mostly to issues of acceptability such as easy access, shorter waiting time, longer or flexible opening hours, better availability of staffs and necessary drugs, better attitude of health service provider giving patient hearing to the problem of client, sufficient time for examining them and explaining them about their problem, more confidentiality in socially stigmatized diseases.

The health seeking behavior and choice of care provider is largely determined by type of symptoms experienced for the illness and duration of illness in number of days. Traditional beliefs tend to be intertwined with peculiarities of the illness itself and a variety of circumstantial and social factors. This complexity is reflected in the health seeking behavior, including the use of home prescriptions, delay in seeking bio-medical treatment and non-compliance with treatment with and with referral advice. The attitude of the health provider and patient satisfaction with treatment play a role in health seeking behavior. The role of patient satisfaction is a crucial determinant for utilization and success of health care delivery system and its long term viability. The World Health Organization has created a performance system based on five composite measures in which health system responsiveness (patient satisfaction and its distribution in the population of varying economic status. Studies in the developing world have shown a clear link between patient satisfaction and a variety of explanatory factors, among which service quality is prominent.16

The aim of this study was to see the utilization of services provided by community clinic, assessing its performance achieving delivery of essential service package to the community people and also to see the perception of the community people regarding the quality of services.

1.2. Justification of the studyIncreasing attention has been paid to the quality of care as a means to enhance the effectiveness of health care systems in developing countries. Patients perception of quality of care is critical to understand the relationship between quality of care and utilization of health services and increasingly it is treated as an outcome of healthcare delivery.17-20 Experiences in Bangladesh21, Vietnam22, BurkinaFaso23 provide growing evidence that the perceived quality of health care services and other socio-cultural and economic factors has a strong impact on utilization patterns.24 The study on several dimensions of perceived quality of health care service in Bangladesh including responsiveness, assurance, communication, discipline and bakhsis (unofficial payments) shows arbitrarily, that these factors have a relatively greater influence on individuals decision regarding utilization compared with access and costs.

The public sector health services are unsuccessful providing health and family planning services according to the expectation of people. The government adopted a strategy to build up a partnership of public sector facilities and the providers with the community to address the health needs of the local population efficiently and effectively and to ensure a long term sustainability of the essential health care provision and thus to support service development. Community clinics have been considered as the entry point of partnership between government and the community with a view that community will be involved in management and operation of community clinics participating from site selection, land donation, supervision of its construction, operational management, day to day repair and maintenance as well motivating the community to bring change in their health seeking behavior. As the outreach centers, satellite clinics which were serving as means of delivery of ESP are gradually being replaced by community clinics and the domiciliary services will be only in a limited form for groups or individuals who are at risk, the most neglected including the extreme poor, follow up on drop-outs for family planning for back referred cases. So its very important to see and monitor whether the community clinics are meeting their objectives set for them in HNPSP for providing ESP services efficiently and effectively.

It has passed more than 2 years that the community clinics have made functional. The Ministry of Health & Family welfare is claiming that on an average everyday twelve patient are getting health care services from the community clinics. The study on improving access to health care for the poor and vulnerable in Bangladesh shows that the overall activities of community clinics covered by the survey are not impressive and as a result, the objectives of the community clinics are not being fulfilled as had been hoped. Most of the clinics were found to be closed and none had any drugs when the survey was conducted. The quality of construction was also found to be poor at some of the surveyed community clinics. Lack of essential drugs at the community clinics has already given a bad reputation for being an unreliable source of health care.

Community clinics have the potential to be a major source of health services for the poor and vulnerable and there are also risks in that some previously successful outreach services are to be replaced, and there is a need to ensure that the benefits of these are retained.This study aimed to find out the perception of the community people regarding the quality of services which is considered as a very important factor for utilization of health care delivery services.

This study finding might help giving important information which would help the policymakers in formulating strategies for further improvement in the initiative and thus utilization of community clinic. For strengthening this initiative identification of problem as well as factor related to utilization is very important. Until and unless the barriers are identified the service cannot be improved.

1.4 Research Questions To what extent the ESP services of community clinic are utilized by the target population? What is the perception of the study sample about the quality of services provided by community clinic? What are the predictors influencing utilization of community clinic?1.5 ObjectivesGeneral objectives

To determine the utilization of ESP services provided by the community clinic and its predictors.

Specific objectives1) To estimate the utilization of ESP services provided by community clinic.

2) To determine the perception of the study sample about service quality of

community clinic.3) To assess the influence of their perception on utilization of those services.

4) To determine the influence of socio-economic status of study sample of

community clinic.

5) To identify the predictors of utilization of ESP services provided by the community clinic.

1.6 Variables in the study

Socio- demographic variables

1. Age

2. Sex

3. Educational status of the sample

4. Occupation of the sample

5. Number of family members

6. Monthly Expenditure on average

7. Ownership of residence

8. Housing Condition:i. Construction material of the floor

ii. Construction material of the roof

iii. Construction material of the wall

9. Possession of land for their residence

10. Possession of land for cultivation

11. Source of drinking water

12. Source of lighting

13. Type of latrine uses

Key variables related to utilization of services

1. ImmunizationA. For children under two years of age- Whether the child was vaccinated from community clinic.

B. For female of reproductive age group (15-49 years)

Whether immunized with tetanus toxoid or not?2. Contraceptive methods If the eligible couple

Using contraceptive methods regularly or not

Whether procure contraceptives from community clinic

3. Ante-natal care (in her last pregnancy)

Ante-natal care from community clinic Yes/ No

4. Post-natal care

5. Treatment of children for minor illness6. Treatment of other family members for minor illness

7. Registration of the pregnant women

8. Health education on personal hygiene, care of new born, care of pregnant mother,

danger signs of pregnancy etc.

Variables related to perception of quality of Health care service:

Health care related:

1. Capability of the health care personnel in community clinic to find out what is

wrong with the patient. 2. Capability of the health care personnel to prescribe the drugs that are needed by the patient.

3. Availability of drugs in the Community Clinic.

4. Quality of the drugs that are supplied from the Community Clinic.

5. Outcome of the patient treated in community clinic.Health personnel related:

1. Skill of the health personnel examining the patient in Community Clinic.

2. Follow up of the recovery of patients by the health personnel in Community Clinic.

3. Empathy in the attitude of the health personnel towards patient in Community Clinic.

4. Respect for the patient in the attitude of the health personnel in Community Clinic.

5. Openness of the health personnel with the patient while providing services.

6. Time they spend examining the patient.

7. Time they spend for explaining patient about their illness.

8. Honesty of the health personnel, working in the Community Clinic.

Health care Facilities related:1. Distance & accessibility of the community clinic.

2. Equipments in the community clinic.

3. Fee charged in the community clinic.

4. Opportunity of fee waving.

5. Number of health personnel in the Community Clinic adequate or not.

6. Health personnel for treating womens disease.

7. Waiting and examination room for the patients in the Clinic.

2 Literature Review

This study was designed to estimate the utilization of Essential service package (ESP) services provided by the community clinic, determine the perception of the study sample about service quality of community clinic and assess the influence of their perception on utilization of those services. For the in-depth conceptualization of the study problem, acquiring the background information and for selecting appropriate methods a considerable number of research articles published in different national and international journals, reports, abstracts and textbooks were reviewed thoroughly and critically. For the search of literature various organizations and institutions libraries specially library of National Institute of Preventive and Social Medicine, Dissemination and Information Service Center (DISC) of International Center for Diarrhoeal Disease Research, Bangladesh (ICDDR , B) and different websites were explored.

2.1 Community Clinic

The community clinics are the public health care delivery centers at the grass root level to deliver the initial services of ESP. These community clinics are to bring family planning, preventive health services and limited curative services closer to the population, and to improve the efficiency of service provision, partly by replacing outreach services provided from a fixed point. Community clinics (CC) are to provide services for around 6000 people, and it is envisaged that their location would make them accessible for 80% of the population within less than 30 minutes walking distance. The design is to be simple - two rooms with drinking water and lavatory facilities, and a covered waiting area. Funds for building the clinics were provided centrally, but communities are to donate land. This is planned to create the sense of ownership in the community.

Each clinic should have two staff, one health assistant and one family welfare assistant. There is a specified allocation of equipment and a range of drugs necessary to deliver the ESP services. Staff from the community clinics would continue to provide a limited range of outreach services, especially in the early period after opening, and staff from higher levels in the system would visit on a regular basis to provide additional services and to supervise the community clinic staff. The development included a training programme for community clinic staff.2.1.1 Background

Before introduction of Health and Population sector programme (HPSP) on 1st July 1998 the Ministry of Health and Family Welfare (MOH&FW) used to have two separate cadres at all levels to provide and manage health and family planning services. Often the clients could not obtain health, reproductive health and family planning services from the same service point. The separate service structure was an impeding factor for delivering the planned ESP because it had integrated health and family planning services. Therefore, the government decided to reorganise services by unifying health and family planning services at upazila level and below. It decided to provide services in a three-tiered fixed facility-based one-stop delivery system, with the Upazila Health complex (UHC) at the upazila level, the Union Health and Family Welfare Center (UHFWC) at the union level, and the community clinics (CC) at the ward/village level.

There is shift from the home-based to a static centre-based service-delivery system. The five year plan (1998-2003) of the MOH&FW is aimed at providing a range of essential health and family planning services i.e.the ESP, specially to the vulnerable groups, i.e., women, children, and the poor. The HPSP has delineated three basic features for delivery of the ESP:

Client-oriented services

Unified management and

One-stop service-delivery.

There was interruption of services of the community clinics as the policymakers decided to shift from the concept of community clinic during 2002 to 2009. But for about last two and half years they have been re-opened and till date 10,322 community clinics are functioning and measures are already taken to strenghthen them through increasing manpower and logistics. 2.1.2 The concept of design of community clinic To meet the reorganized service-delivery strategy at the community level, fixed-site clinics featuring a one-stop service centre, referred to as community clinic (CC), under the supervision of a unified management, will gradually replace the existing home-visit approach. Given the substantial changes suggested in the HPSP, the implementation of ESP delivery, including operationalization of CCs, need close monitoring to derive sufficient information to fine-tune and modify the approach as required.

1. One stop service: As many behavioural change communication and other services as possible would be provided at one place on each working day.2. Accessibility: Maximum half an hour travel-time to the service provision point.

3. Coverage: 80% coverage of population living within the half an hour walking distance to the service points.

4. Quality: Services to be provided according to the defined standards.

5. Efficiency: Providing more services for the same costs, or same services at less cost, in a more accessible way.

6. Community participation: Involvement and participation of community in designing, planning, monitoring and helping to implement the program. The community is to donate the land in a suitable location and assist in constructing the clinic.

7. Population based planning: Services are based on the needs of the defined population.

8. Technical competence: Availability of skilled human resources with multiple skills.

9. Logistic and supply: Availability of medicines, vaccines, cold chain and instruments according to the level of services.

2.1.3 The functions of community clinics are:

1. Registration of pregnant women

2. Behavioural change communication on hygiene, diet, immunization, breast-feeding etc.

3. Informing pregnant women in advance to attend the clinic for family welfare volunteer services and ensuring that pregnant women come for antenatal services.

4. Maintaining the expected date of delivery information to provide assistance if danger signals appear.

5. Referral to higher levels

6. Providing FP methods including pills and condoms

7. Informing families in advance about outreach clinics and ensuring that children are immunized at the correct times.

8. Oral Rehydration Salt, Vitamin-A, Anti- helminthics, Acute Respiratory Infections, Direct observed treatment strategy for Tuberculosis, Multi-Drug resistant Tuberculosis for Leprosy, Anti-malaria etc.

2.2 The community clinic and ESP services:

It is already mentioned earlier that under the HPSP, the ESP be delivered in a three-tiered service-delivery model. At the grassroots and community level, the new service-delivery model warrants a shift in approach from the current home-visitation and makeshift centers (satellite clinics/EPI outreach sites) to the community clinic -based service-delivery plus limited home visits. This indicates that the existing makeshift outreach/satellite clinics and the domiciliary services will be phased out gradually. In the reorganized service-delivery plan, the community clinics will be the only major service-delivery outlet at the grassroots level to provide basic health and family-planning services. Nevertheless, limited home visits by the community clinic providers will still be continued as a back up to prevent dropout of critical services and to provide services for population with limited access.The Health and Population Sector Programme (1998-2003) aimed to bring important changes to health and family planning services in Bangladesh. The introduction of a sector wide approach brought a series of changes in the planning, financing and delivery of services. The government realized the difficulties in providing all the services needed by all segments of the population due to resource constraints. Hence, the policy makers decided to design a health service that would achieve the greatest health impact per taka spent, could be provided in a sustained way, and would satisfy the need of the most vulnerable in the society women, children and poor. Accordingly, the MOHFW devised an ESP for phased implementation in Bangladesh. A key component was the development of the new ESP to meet the needs of the poor, especially in rural areas and particularly women and children. The elements of ESP are grouped into the following five areas:

Reproductive healthcare,

Child health care,

Communicable disease control,

Limited curative care, and

1. Behaviour change communication.

2.3 Utilization of services provided by community clinic A very few study have been conducted on community clinic and the study that was done to see its utilization in 2002 seems to be too earlier and at a stage when the logistic support were withdrawn as per decision of policy level to switch over from the concept of community clinic. Now, we can see that the community clinics have been re-opened for about two and half years and different measures are being taken to strengthen their facilities like employing more manpower and extending coverage of services. As the community clinics have been established with the view to provide the initial services of the ESP that is the service programme formed by the policymakers to ensure the primary health care in our country so studies on the utilization of primary health care in different parts of the world were reviewed for the purpose of the study.

A study of the community clinics: Effects on service delivery, quality and utilization of services to assess the extent to which the community clinics were operating efficiently and effectively, and whether they were meeting the objectives set for them in HPSP in provision of ESP services. Using a combination of quantitative and qualitative techniques the study gathered evidence from service users, local influential people, service providers, managers, planners and policy makers. The study also drew on policy and management documents, routine statistics, and previous studies and reports that included information on community clinics. The sample of clinics covered all parts of the country and included a wide mixture of types of setting.

The Findings of the study are:

1) Location of clinics: The majority of community clinics are well located, in all the senses considered. A minority are very poorly located, with flooding and very difficult access. The travel time criterion is not easy to meet in areas of relatively sparse population, but in most cases it was met or nearly met.

2) Construction of clinic buildings: Most of the community clinics in the study have the specified two rooms and are built using appropriate materials. In many cases the quality of construction is below the necessary standard, and buildings are already showing signs of dilapidation. All community clinics are expected to have two operational toilets and safe drinking water. Very few met these standards, with many having only one toilet, and even these were in poor condition. Few had safe drinking water.

3) Furniture and equipment: Most community clinics were found to have some items, but few were found to have all the specified furniture, and almost none have all the specified equipment. Deficiencies are sufficiently serious to have effects on service quality. 4) Community participation in development and operation of community clinics: In most cases community groups (CGs) are set up, but few working effectively. Previous experience in Bangladesh suggests that there is a need for effective mechanisms to allow more ownership by local communities, but this is not yet happening in community clinics.

5) Staff posting to community clinics: Some community clinics have the two staff, many have one and in some cases there are no staffs posted. However, even where staff are posted to community clinics it is often difficult to find them and productivity seems low. 6) Skills of staff: Staff in community clinics are provided with training, and some of this training is good. 7) Supply of drugs: In most cases most of 23 drugs are being available at the time of opening, but supplies are limited and intermittent. The arrangements for supply of drugs to community clinics are falling behind to achieve even a reasonable level of availability.8) Opening hours: Half of the community clinics are effectively closed, and are providing little or no service. In a quarter of the clinics the services are often available, and in other cases opening was erratic, and often only limited services such as immunization are available. 9) Service quality: Evidence from this study suggests that the perceived quality of services, including behaviour of providers, is considered poor by the users.

Another study on improving access to health care for the poor and vulnerable in Bangladesh covered 93 respondents from 12 community clinics spread over five districts. The study shows that the overall activities of community clinics covered by the survey are not impressive and, as a result, the objectives of the community clinics are not being fulfilled as had been hoped. Most of the clinics are closed and none have any drugs during the survey. The quality of construction is also poor at some of the community clinics. Lack of essential drugs at the community clinics are giving a bad reputation as an unreliable source of health care.

An average of about 40 patients attends the surveyed community clinics each day as long as the supplied drugs lasts. Most of the patients are reported to be women and children and from poor backgrounds. This suggests that community clinics have the potential to be a major source of health services for the poor and vulnerable.

There are gaps of 2-14 days when services are not being provided even when drugs are in stock. The reasons cited for these were weekly and national holidays and the service providers attending meetings, conducting field visits, preparing Geographical Reconnaissance and managing satellite clinics.

Study conducted in forty community clinics to analyze the maternal health care delivery system in Bangladesh by the MOH & FW and the London School of Hygiene and Tropical Medicine finds that 31(78%) community clinics are non-functioning. The study reported that out of the 9 functioning community clinics around half are functioning in a clean environment. The others do not have either water supply, or usable sanitary latrines. The study finds poor physical location as a major barrier to access to these community clinics. Only six of the forty community clinics surveyed (15%) are to be easily accessible. Almost 85% are poorly located either in terms of approachability or difficulty in access due to inappropriate site selection. Some are accessible only by boat.As regards to community groups the study report shows that 71% of the community groups are not functioning or not formed at all. Supervision and monitoring of the clinics by the higher authority is not in line with government policy. Most are visited only occasionally, and not as per the schedule prescribed by the government.

Most of the community clinics surveyed are poor performing. The use of these clinics by the local people is low. Only 19 percent of the clinics surveyed remains open on all working days. Twenty-eight percent are open once a week while 38 percent clinics are reported to be open only once in a month. Fifteen percent of clinics are closed after formal opening. The mean time open per day is 2 hours (0.5 hour). The study finds that the poor performance is also due to the acute shortage of drugs and equipment. On an average, these clinics reported not more than 7-10 patients a day. Despite a very low use and attendance of patients in the clinics, the mean consultation time for the patients in these clinics are only 0.73 minutes (0.5 minutes). This suggests a lack of motivation among the service providers of community clinics to perform their jobs. Twenty six percent of the service recipients said that the community clinics lack privacy, 21% mentioned unavailability of drug and medical supplies, 20% reports rude attitudes of service providers. Inadequate clinical skills among providers are also reported.2.4 Utilization of primary health care -

A study by Lartson et al. done in 1984 in rural clinics in Ghana assessed the process of providing maternal and child care13. They compared actual (observed) performance levels with expected levels for a number of diagnostic, therapeutic and counseling tasks. They found significant performance gaps, especially in the area of physical examination and in the counseling of patients or clients.[[[[[[one of the first large-scale comprehensive efforts to provide detailed information on how primary health care services were delivered in developing countries was carried out by the United States AID -financed Primary Health Care Operations Research (PRICOR) project (1985-1992) whose studies spanned 12 countries. Using a direct observation of over 6000 patient-provider encounters, this project uncovered severe deficiencies in the diagnosis, treatment, and counseling of patients as well as in the supervision of health workers for the following primary care activities: Growth monitoring and promotion, immunization, case management for malaria, diarrhea and acute respiratory infections.11Similarly, Sauerborn et al.25 analyzed maternal and child health services in a rural districtof Burkina Faso. They reported that especially the task of screening for risk factors in both under fives' clinics and antenatal clinics was came out well below standard. They also found that communication in both curative and preventive clinics was poor, e.g. only 5% of mothers who brought their children to under fives' clinics received any kind of counseling during their visit.

Bjorck et a!. observed 539 primary care visits and found that, according to local standards of care, only 65 (12%) of the patients were adequately diagnosed and treated.26 The same weakness in the process of primary health care provision was reported by Gamer et al. for managerial tasks, such as cold chain support and maintenance in 76 rural health centers in Papua New Guinea.27 It is therefore no surprise that community satisfaction with the primary health care service is low, specially in the domain of interpersonal skills of health personnel. Gilson et al found it from a study in Tanzania.28All those study findings can be summarized to identify the reasons for poor or bad quality of services in health care delivery in developing countries. Though there are scaracity of human resources, buildings, equipments and finance to run the services but besides other conceptual reasons are there which delayed the tackling the issue of quality of care in these countries.1. Overemphasis on quantity and access. In the Alma Ata Declaration, 1978 the issue of primary health care got the priority to be on the fore front of the health policy agenda which decisively altered the health policies. The declaration emphatically embraces community participation in health care and stresses the links between the health and other sectors of the society. As far as health care delivery is concern, the key issues are access and affordability. Although the declaration underlines the the importance of efficiency of service delivery and performance to recover costs, it does not mention quality let alone provide any guidance of how the quality of primary health care could be achieved. The poor perceived quality of health care delivery services keeps people away from utilizing public health care service.2. Inappropriate focus on inputs. Of the three elements of the Donabedian triad of structure, process and outcome, the focus is put on the structure assessing quality.12 The reality in many developing countries made it tempting to equate lack of quality with the absence or shortage of inputs.3. The new concern for quality: The recognition that the quality of many health services was, indeed, low. While the efforts are in right direction but the public health sector is plagued by uneven demand and perceptions of poor quality. The underutilization of available facilities is of significant concern countrywide. For example one study done by Ricardo et al on 2004 showed that the overall utilization of public health care services is as low as 30%.29 2.4 Factors related to utilization of health care

Not only in the developing countries also the developed world recognize the importance of patient satisfaction and his good perception on health care delivery services for their long term viability and success. Donabedian in his study (1988) suggests that patient satisfaction may be considered to be one of the desired outcome of care.30 The patient who endures physical, psychological, economic, social experiences during the overall health service delivery process would be able to make an appropriate evaluative judgement of how they are treated, as reflected in their overall satisfaction or dissatisfaction measures.

Studies in the developing world have shown a clear link between patient satisfaction and a variety of factor, among which service quality has been prominent14.This link is also important in the health care system of Bangladesh. Earlier studies showed that service quality can be measured by using SERVQUAL framework33.

The service factors responsible for the patient satisfaction as per the framework are as follows:

1) Reliability it is the providers ability to perform the promised service.

2) Responsiveness health personnel to promptly respond to the patients need.

3) Assurance it is the knowledge, skill and courtesy of health personnel tht assures the patient to sense the best.

4) Tangibles Physical evidence that the health care facility will provide satisfactory services.

5) Communication that the patient ae consulted about the type of care and they never feel to be left alone.

6) Empathy Health personnels empathy and understanding of patients problem.

7) Process feature it is the orderly management of the overall health care service process.

Besides service factor two additional factors are related those are cost of the service and its availability.

It is the conclusive outcome from those studies in the developing countries all over the world that quality assurance, the main tool for quality improvement in the developing countries. In quality assurance the first focus is on process but also not ignoring the need to improve outputs. 2.5 Perceived quality care and utilization of community clinicPatients perception of quality of care is critical to understand the relationship between quality of care and and utilization of health services16-18. Experiences in Bangladesh19 and also in China31, Nepal32 and other countries provides growing evidence that the perceived quality of health care service has a strong impact on utilization patterns. The low utilization of both community health workers and first line health services was, to a large extent, due to consumers' perceptions of low quality of care.It has become clear that the consumers are only willing to pay for health services, and thus generate the revenues to fund them only, if they perceived that the services to be of reasonable quality.

2.5.1 Assessment of perceived qualityThe 20-item scale includes three subscales related to health care delivery, personnel and facilities. There were 241 people in one city and two villages in Upper Guinea who responded to the questionnaire.33 An item analysis preceded the test of psychometric properties of the three subscales and of the total score. Reliability was estimated by analyses of internal consistency and the Cronbach's alpha coefficient. A variety of statistical procedures were used to test factorial validity, trait validity (convergent and discriminant) and nomological validity. Results confirm the value of the use of the scale developed and highlight the need to take into account the diversity of how quality is perceived by lay people in developing countries. It is suggested that the process of formalization of this type of measurement scale be pursued.The questions were worded so that they could be administered during individual interviews, with the interviewer recording the answers. For each question, respondents could express one of three opinions:

a) unfavorable (1), b) neutral (0), or c) favorable (+1).

Of the 47 original items, 20 were retained and categorized into three groups (see Appendix). The first group included five items related to health care delivery: one item dealt with diagnosis, one with the care outcomes, and three with drugs (prescription, quality and availability). The latter are known

to be of prime importance to users of services in developing countries and are among the main reasons for resorting to care [11,4045]. The second group of items included eight items referring to the attitudes and practices of the health care workers: patient follow-up, clinical examination (which is not systematic, and is considered as a mark of attention from the health care staff), the reception of the patient, compassion, espect, time spent, explanation given on the health problem, and lasdy, the honesty of the staff. The sevenitems in the third group focused more specifically on the health care facilities. Three items referred to accessibility and dealt with the adequacy of the fees, the possibility of making special payment arrangements (credit), and distance. Four other items dealt with resources: the adequacy of the number of doctors (as in other countries, this term is used in Guinea to designate the majority of health care providers), doctors for women's treatment, equipment and rooms.The utilization of health care delivery services at grass root level to obtain health, reproductive health and family planning services from the same service point by skilled health personnel through their sympathetized care towards the patient with assurance of quality of treatment and availability of necessary drug gives a good perception on the quality of care. A single structure for health care delivery also makes the proper utilization of minimum resources.3. Materials and Methods

A study was conducted to estimate the utilization of services provided by the community clinic, determine the perception of the study sample about service quality of community clinic as per following methodology:

3.1 Study design A cross sectional study was conducted to estimate the utilization rate of community clinic and determine the influence of perceived service quality and assess the socio-economic predictors on utilization of community clinic.3.2 Study period:

A total period of the study was from January to June 2011. It was started with literature review, then protocol preparation, data collection and finished with final report submission. After development of questionnaire by the 2nd week of April data were collected in last week of April and 1st week of May. Data processing and analysis were performed in the 2nd and 3rd week of May and report writing and interpretation were done from the 4th week of May to the 1st week of June (work schedule is annexed).3.3 Place of the Study:

The study was undertaken in the catchment area of Meghdubee community clinic, located at the Pubail union of Gazipur sadar upazila in Gazipur district. The catchment area covered the whole Meghdubee village which includes three wards no 5,6 and 7 of pubail union. The community clinic was located by the side of highway besides a school with very easy and good accessibility from its whole catchment area. Its a two room structure with a covered waiting area with toilet & water facilities and an open space in front of it (Annexure-4). 3.4 Study population:

All the households having children less than 2 year of age in the catchment area of Meghdubee community clinic were included as study population. As the community clinics were re-opened for the last two and half years so the households having children less than 2 year were selected as study sample to see the utilization of services among them. As the community clinic were re-opened for the last two and half years so the households having less than 2 years children were selected as study sample to see the utilization of services among them.

3.5 Sample Size:

One hundred and two household having children less than 2 years of age in the catchment area of Meghdube community clinic were recruited in the study. 3.6 Sampling Technique:

Purposive sampling was adopted. All the households in the catchment area of Meghdubee community clinic who fulfilled the study selection criteria (having children less than 2 years of age) were included in the study. As the community clinics were re-opened for two and half years so the selection criteria of study sample was determined as household having mother with less than 2 year children.3.7 Data Collection Instrument:

A semi structured questionnaire was developed in English (Annex-2). The questionnaire was developed using the selected variables according to the specific objectives. The questionnaire contained questions related to:1) Socio-demographic characteristics, 2) Aspects of treatment and health care, 3) Perceived quality of health care services and 4) Service received from the community clinic.

To measure the perceived quality of health care a 20-itemed scale comprising questions related to health personnel, adequacy of resources and services, health care delivery, and financial and physical accessibility, The scale was developed and validated by Haddad et al 21, The English questionnaire was translated into Bangla (Annex-3). Pre-testing was done in the catchment area of adjacent Kudabo community clinic among seven respondents for checking the appropriateness of wording and sequence of questions. According to the findings of the pre-testing necessary changes were made.3.8 Data collection technique: Data were collected through face to face interview of the household at their residence by using the questionnaire. Before the interview, the detail of the study was explained to the eligible household and their verbal consent was obtained. The characteristics of head of the head of the household were obtained by interviewing head and the other necessary informations were mostly collected from the mother of the children. Both the parents who were present took participation in the interview.

To cross check the information provided by those regarding immunization of the children and mother the immunization card of the children and mother were reviewed. 3.9 Data processing and analysis:

After data collection, each questionnaire was checked to see whether it was filled completely. Then they were stored after giving identification numbers. The data were entered into computer with the help of Software Statistical Package for Social Sciences (SPSS) for windows version 19.0. After frequency run, data were cleaned, edited, coded and computed, edited, recoded computed. By using the 20-itemed scale the total scores got from the study samples were categorized into four quartiles.

Data were presented by tables and graphs.

The quantitative data were analyzed to find out the mean, standard deviation and test of normality.

The qualitative data were categorized into different categories based on their characteristics. Statistical analysis was done mainly to see the association, significant differences between the outcome and different independent variables. The variables of different services were analyzed with different socio-economic variable to see their influences whether statistically significant or not.The association between utilization of different services and different categories of perception were tested by doing (2 tests. [Logistic regression will be done to remove the effects of confounders.]3.10 Ethical considerations

Prior to the initiation of the study ethical clearance was taken from the NIPSOM Ethical Review Committee. The study included neither included any invasive procedure nor any private issue and no drug was tested. Before initiation of the interview a brief introduction on the aims and objectives of the study was presented to the respondents. They were informed about their full right to participate or refuse to participate in the study. A complete assurance was given that all information provided by them will be kept confidential and their names or anything which can identify them would not be published or exposed anywhere. After completion of these procedures the interview will be started with their due permission. The research was conducted in full accord with ethical principles.3.11 Limitations of the study

Although maximum care had been taken by the researcher at every step of the study, still some limitation exists:

Since its a cross sectional study, the association it suggests might not be a true association. The study was conducted on a small sample the household having children less than 2 year of age in the catchment area of one community clinic due to time constraint. Therefore it might not represent all the community clinics of the country. The questionnaire though its reliability was done through pre-testing but as it was not validated may not be sufficient to serve the purpose for measuring perception accurately The scale that used for measurement of perceptions was though validated at their place of study and appeared to be an appropriate instrument to assess patient perceptions on quality of care. But the categories of perception bad, average, good and very good were made by doing quartiles of the total score we got from the study samples is subjected to be the reflection of the perceptions of that specific population studied.

For measuring perception only quantitative studies were not sufficient, arrangement of focus group discussion could have given better result. 4. Results

A cross sectional study was conducted to assess the utilization of community clinic A total of 102 households having children less than 2 years of age were selected as study samples. The analyzed data are presented in this chapter through tables and graphs.

The results of the study are described in the following sections.The influences of different socio-demographic factors like education, occupation, monthly expenses, family size, possession of land for housing on utilization of different services of community clinic were determined.4.1 Socio-demographic characteristics of the households

In this study the socio-economic characteristics of the selected households including monthly expenses, housing condition, possession of land, source of drinking water and light and type of latrine used and as well as characteristics of household head were collected. This section shows frequency of the related variables. 4.1.1 Data related to head of household

4.1.1.1 Age and sex All the household head were male except one female. In this study the age of the head of the household varied from 20 to 59 years with the mean age of 31.41 years and standard deviation 7.02 years. The age was categorized into three categories. The frequency distribution showed that the 20 to 29 years and 30 to 39 years age group included equal proportion of respondents (45.1% and 44.1%, respectively) [Table: 4.1].4.1.1.2 Educational status

The educational status was categorized into three categories and almost half of them were in primary to below secondary (47%) level educated.[Table 4.1]4.1.1.3 Occupational status

The occupational status of the households were broadly categorized into four categories and lowest were skilled labourer (13.7%), and highest, businessmen (41.2%) [Table 4.1].4.1.2 Household characteristics4.1.2.1 Religion All the one hundred and two respondents were Muslims4.1.2.2 Family size

According to number of family members households were categorized into two family types. The frequency distribution showed that 59 were of family with having four or less members (57.8%) and rest were with bigger families [Table 4.2].4.1.2.3 Average monthly expenditure

According to the average monthly expenditure the households were divided into three categories. Frequency distribution showed that 38.2% of the households were having average monthly expenditure of taka 5,000 or less, 49% between taka 5,001-10,000 and rest were having monthly expenses more than taka 10,000 [Table 4.2].4.1.2.4 Land for residence Frequency distribution showed that 48% of the household had land less than five decimal for their housing and rest were having more than five decimal of land.[Table 4.2]4.1.2.5 Cultivable landMajority of the household (69.6%) had no land for cultivation and 18.6% had land more than 50 decimal [Table 4.2].4.1.2.6 Source of drinking water

It has been found that 72 (69.6%) of the respondents were using water from shallow tube well [Table 4.2].4.1.2.7 Source of light

Majority (84.3%) of the respondent used to have electricity as their source of light.[Table 4.2]4.1.2.8 Type of latrine

Majority of the respondents (55.9%) used water sealed latrine and additional 37.3% used latrine with septic tank.[Table 4.2]

Table 4.1. Characteristics of household headCharacteristicsFrequencyPercentage

Age20-29years4645.1

30-39yrs4544.1

40yrs1110.8

EducationalstatusPre-primary2726.5

Primary to below secondary4847.0

Secondary and above2726.5

OccupationUnskilled labour2019.6

Skilled labour1413.7

Service holder2625.5

Business4241.2

Table 4.2 Socio-demographic characteristics of the household:CharacteristicsNo. of the householdsPercentage

Family size45957.8

>44342.2

Monthly expenses(in taka)50003938.2

5001-100005049.0

>100001312.7

Living land possession10000 was 11.1% so with the increase in the monthly expenditure the use of contraceptives from the community clinic decreased but 2 test did not find any association [Table 4.3].4.2.1.4 Ownership of land for residence and utilization of community clinic for

contraceptives:Those having land for housing 5 decimal used to take contraceptives from the Community Clinic 46.5% more commonly than those having land for their housing >5 decimal (40.0%). [Table 4.3]4.2.1.5 Family size and utilization of community clinic for contraceptives:Regarding size of the family those having 5 or more members were utilizing contraceptive services (39.5%) relatively less than those having 4 or less member (46.0%). The 2 test did not find any association. [Table 4.3]Table 4.3.Utilization of contraceptive delivery services from the community clinic and socio-demographic characteristicsCharacteristicsContraceptives delivery services2p -value

NoYes

EducationN%N%4.58NS

Pre- primary education1246.21453.8

Primary to below secondary2253.71946.3

Secondary and above level1676.20523.8

Occupation1140.71659.34.10NS

Skilled and unskilled labour1463.60836.4

Service Holder2564.11435.9

Business1140.71659.3

Average monthly expensess5.62.

NS

5000 Tk.1645.71954.3

500110000Tk.2659.11840.9

> 10000Tk.0888.90111.1

Land possession for residence0.38NS

5 decimal land2353.52046.5

>5 decimal land2760.01840.0

Size of the family0.37NS

Having 4 or less member2754.02346.0

Having 5 or more member2360.51539.5

4.2.2 Utilization of community clinic for ante-natal care

The figure 4.2.2 shows fifty eight pregnant mothers (56.9%) had the ante-natal care from the community clinic and the rest forty four mothers did not receive that from community clinic. [Fig 4.2]

4.2.2.1 Educational status of the household head and utilization of ante-natal care service:It has been found that the utilization of ante-natal care services from the community clinic among the pre-primary level was 55.6% and in primary to below secondary level was 63.8%.The utilization of ante-natal care from community clinic in educational status of secondary and above level was 40.7%.So the people having higher level of education was less utilizing the ante-natal care services from community clinic. The 2 test did not find any association. [Table 4.4]4.2.2.2 Occupation of the household head and utilization of ante-natal care servicesIt has been found among the occupational categories the skilled and unskilled labourer group were utilizing ante-natal care services from the community clinic 61.8% more than the service holder (53.8%) and the business (50%) group. The 2 test did not find any association. [Table 4.4]4.2.2.3 Average monthly expenditure of the household and utilization of ante- natal care service:It has been found that the utilization of ante-natal care from Community Clinic in the group with average monthly expenses of 5000 was 56.4%, in group with monthly expenses 5001-10000 was 57.1% and in the group with monthly expenses >10000 was 46.2%.So we can say that those having average monthly expenses more than 10000 were utilizing the ante-natal care services less from the community clinic. The 2 test did not find any association. [Table 4.4]4.2.2.4 Ownership of land for housing and utilization of ante-natal care service:Those having land for their housing 5 decimal were utilizing the ante-natal care services from the community clinic 59.2% more than those having land for their housing >5 decimal and were utilizing 51.9% ante-natal care services from community clinic. The 2 test did not find any association. [Table 4.4]4.2.2.5 Size of the family and utilization of ante-natal care service:Regarding size of the family those having 5 or more member were utilizing ante-natal care services (65.1%) relatively more than those having 4 or less member (50.8%).

The 2 test did not find any association. [Table 4.4]Table 4.4 Utilization of ante-natal care from community clinic and socio- demographic characteristics

Socio-demographic characteristicsAnte-natal care 2 p -value

NoYes

EducationN%N% 2.35NS




Occupation1132.42367.6 4.77.NS

Skilled and Unskilled labour1246.21453.8



Average monthly expensess 0.91NS

Expensess 50001538.52461.5

Expensess 5001--100002244.02856.0

Expensess > 100000753.80646.2

Land possession for residence 1.58NS






4.2.3 Utilization of community clinic for tetanus immunization to pregnant mothers

The figure 4.3 shows that eighty seven (85.3%) pregnant mothers had their vaccine for tetanus during pregnancy from the community clinic.[Fig 4.3]

4.2.3.1 Educational status and Utilization of immunization of pregnant mothers for tetanus:The frequency distribution shows that the service of Community Clinic for immunization of pregnant mothers for tetanus was more utilized group of pre-primary education 100% than utilized in primary to below secondary and secondary and above level where utilization were 70.2% and 81.5% , respectively. The Fischers exact test found association and the p value 10000 was 84.6%.So it can be said that those having average monthly expenses of 5000 were utilizing immunization of pregnant mothers for tetanus more than others from community clinic. The 2 test did not find any association. [Table 4.5]4.2.3.4 Ownership of land for housing and utilization of immunization of pregnant mothers for tetanus:Those having land for their housing 5 decimal were utilizing the immunization of pregnant mothers for tetanus from the community clinic 85.7% more than those having land for their housing >5 decimal and were utilizing 84.9% immunization of pregnant mothers for tetanus from community clinic but the difference in uses was very insignificant. The 2 test did not find any association. [Table 4.5]4.2.3.5 Size of the family and utilization of immunization of pregnant mothers for tetanus:Regarding size of the family those having 5 or more member were utilizing immunization of pregnant mothers for tetanus (88.4%) relatively more than those having 4 or less member (83.1%). The 2 test did not find any association. [Table 4.5]Table 4.5 Utilization of immunization of pregnant mothers for tetanus and Socio-demographic characteristicsSocio-demographic characteristicsImmunization of tetanus for pregnant mothers2p -value

NoYes

EducationN%N%**7.62.02


Primary to belowsecondary1020.838 70.2

Secondary and above level0518.522 81.5

Occupation 1.95NS




Average monthly expensess1.05NS

5000 Tk.0410.33389.7

500110000Tk.0918.04182.0

> 10000Tk.0215.41184.6







** Fishers exact test value given.

4.2.4 Utilization of community clinic for immunization to the children

Eighty-two (80.4%) children were vaccinated from community clinic, and the rest twenty two children were not vaccinated from the community clinic. So it can be said that the utilization of vaccination of children from community clinic was 80.4%. [Fig 4.4]

Figure 4.4: Utilization of immunization by children from community clinic

4.2.4.1Educational status and utilization of community clinic for immunization to

the children:The frequency distribution shows that the service of community clinic for immunization to the children was more utilized in the group of pre-primary education 96.3% than was utilized in primary to below secondary and secondary and above level where utilization were 75.0% and 74.1% , respectively.

The 2 test found association. [Table 4.4]4.2.4.2 Occupation of head of household and utilization of community clinic for immunization to the children:Regarding occupational status of the head of the household it was seen that the utilization of immunization to the children was less among the service holder group, 76.9% than skilled and unskilled labour group and business group which were 79.4% and 83.3%, respectively. The 2 test did not find any association [Table 4.6].4.2.4.3 Average monthly expenses of household and utilization of community

clinic for immunization to the children:It has been found that the utilization of immunization to the children from community clinic in the group with average monthly expenses of 5000 was 89.7%, in group with monthly expenses 5001-10000 was 72.0% and in the group with monthly expenses >10000 was 84.6%.So it can be said that those having average monthly expenses of 5000 were utilizing immunization to the children more than others from community clinic. The 2 test did not find any association [Table 4.6].4.2.4.4 Ownership of land for housing and utilization of community clinic for

immunization to the children:Those having land for their housing 5 decimal were utilizing the immunization to the children from the community clinic 81.6% more than those having land for their housing >5 decimal and are utilizing 79.2% Immunization to the children from community clinic but the difference in uses was not very significant. The 2 test did not find any association [Table 4.6].4.2.4.5 Size of the family and utilization of community clinic for immunization to the children:Regarding size of the family those having 5 or more member were utilizing immunization to the children (83.7%) relatively more than those having 4 or less member (78.0%). The 2 test did not find any association [Table 4.6].Table 4.6 Utilization of community clinic for providing immunization services to

the children and socio-demographic characteristicsSocio-demographic characteristicsVaccination of children in community clinic2p -value

YesNo

Education5.90 .05




Occupation0.45NS





5000 Tk.3589.70410.3

500110000Tk.3672.01428.0

> 10000Tk.1184.60215.4







4.2.5 Utilization of community clinic for treatment of children for minor illness:It has been found that thirty six (35.3%) children out of one hundred and two were treated in community clinic for minor illness and the rest were treated in other health facilities, private chamber. [Fig 4.5]

4.2.5.1 Educational status and utilization of community clinic for treatment of children for minor illness:The frequency distribution showed that the service of community clinic for treatment of children for minor illness was more commonly utilized in the group of primary to below secondary (45.8%) than others. The 2 test did not find any association [Table 4.7].4.2.5.2 Occupation of head of household and utilization of community clinic for treatment of children for minor illness:Regarding occupational status of the head of the household it was found that the utilization of treatment of children for minor illness was less among the business group, 31.0% than skilled and unskilled labourers (38.2%) and service holders (38.5%). But the difference was not that significant. The 2 test did not find any association [Table 4.7].4.2.5.3 Average monthly expenses of household and utilization of Community Clinic for treatment of children for minor illness:It was found that the utilization of treatment of children for minor illness in the group with average monthly expenses of 5000 was 38.5%, in group with monthly expenses 5001-10000 was 32.0% and in the group with monthly expenses >10000 was 38.5%.So it can be said that those having average monthly expenses of 5001-10000 were utilizing treatment of children for minor illness less than others from community clinic but the difference was not significant. The 2 test did not find any association [Table 4.7].4.2.5.4 Ownership of land for housing and utilization of community clinic for treatment of children for minor illness:Those having land for their housing 5 decimal were utilizing the treatment of children for minor illness from the community clinic 40.8% less than those having land for their housing >5 decimal and were utilizing 44.4%, but the difference in uses was not that significant. The 2 test did not find any association [Table 4.7].4.2.5.5 Family size and utilization of community clinic for treatment of children for minor illness:Regarding size of the family those having 5 or more member were utilizing treatment of children for minor illness (37.2%) relatively more than those having 4 or less member (33.9%). The 2 test did not find any association [Table 4.7].Table 4.7 Utilization of Community Clinic for treatment of children for minor illness and Socio-demographic characteristicsSocio-demographic characteristicsTreatment of children for minor illness2p -value

NoYes

Education4.73NS




Occupation 0.59NS





5000 Tk.2461.51538.5

500110000Tk.3468.01632.0

> 10000Tk.0861.50538.5







4.2.6 Utilization of community clinic providing limited curative servicesIt was found from their frequency distribution that thirty seven (36.3%) of family members had their treatment for minor illness from the community clinic and rest other than community clinic. So it can be said that limited curative service provided by Community Clinic was utilized 36.3%. [Fig 4.2.6]

4.2.6.1 Educational status and utilization of limited curative care services by community clinic:The frequency distribution showed that the limited curative care services by community clinic was more commonly utilized in the group of primary to below secondary education (54.2%) than utilized in pre-primary (22.2%) and secondary and above level (18.5%).It was found that utilization decreased with the increase in the educational level.

The 2 test found association and the p value was 5 decimal and were utilizing 26.4% and the difference in uses is that significant. The 2 test found association and p value was 10000Tk.1076.90323.1

Land possession for residence4.64.025






4.3 Perceived quality care and utilization of services provided by community clinic

It is the perception of the client over the quality of service delivery and mostly depends on the factors related to the health care facility. Those were relatively little on the structural but more on the availability of health personnel, their attitude towards patient, and their time devotion towards patient in examining their problem, explaining their illness, skill to diagnose problems and prescribing correct drug. Besides the waiting time, waiting and examination room and availability of drugs played role which in the context of country like ours is important.

By analyzing their responses they showed to different components of the 20-itemed scale21 that was used to measure the perception that near about half of the study population had average perception, a little less than one fourth had good perception and more than one fourth had poor perception about the quality of service provided by the community clinic. [Table 4.9].

But the study samples responded differently to few of the components, which were not very similar like we have described above. Though we found from the analysis that the percentage of responses in the good perception category was less than 25% but regarding treatment cost it was 73.5% and to distance of community clinic and quality of the drugs they used to provide were 43% and 41.2%, respectively. Similarly the average perception category showed 82.4% responses regarding waiting and examination room and the responses of poor perception category were maximum to the equipments and availability of drugs, were 74.5% and 53%, respectively.It was found in this study population that perceived quality of care greatly influenced the utilization of services from the community clinic and that was statistically significant. The effects of perceived quality care on utilization of different services are described below:4.3.1 Perceived quality of care and utilization of community clinic services for

contraceptives.No association was observed between perceived quality of care and use of contraceptives from community clinic. But the distribution showed that contraceptives were more commonly used from community clinic by those who had very good perception (63.2%) followed by those with average perception [Table 4.10].4.3.2 Perceived quality of care and utilization of community clinic for ante-natal careIt was found that the utilization of ante-natal care increased with the improvement in perception level and those with very good perception utilized ante-natal care most commonly (86.4%) while 15.4% of the poor perceived respondents utilized the service.(p90%). The Fishers exact test found the difference significant (p 85%). The 2- test found their significant difference (p

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perception of lay people regarding community health care service