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Pro gradu ­tutkielma koostuu seuraavista osista: Rouvinen, Kaisa. Lisääntymisterveydenhuollon haasteet ja naisten hyvinvointi vähiten kehittyneissä maissa. Tampereen yliopisto. Terveystieteen laitos. Kirjallisuuskatsaus. Osasuoritus Pro gradu ­tutkielmaan. 26 s. 2003 Rouvinen, Kaisa. Quality of care in reproductive health services at health posts in Nepal. International EuroQuan Conference on Quality and Nursing Practice. Proceedings. Norsk sykepleieforbund. 1997; 224-231. Rouvinen, Kaisa. Quality of care in reproductive health services at five government health posts in Siraha District, Eastern Nepal. A dissertation submitted to the University of Liverpool (School of Tropical Medicine) in partial fulfilment of the degree of Master in Community Health. 95 pages. 1996 ; 1. JOHDANTO 6 2. LISÄÄNTYMISTERVEYS KEHITYKSEN INDIKAATTORINA 7 3. NAISEN ELÄMÄN TÄRKEÄT JA KRIITTISET VAIHEET 10 3.1. RASKAUS JA SYNNYTYS - TURVALLISEN ÄITIYDEN TAVOITE 10 3.2. PERHESUUNNITTELU JA ABORTTI 15 3.3. HIV JA MUUT SUKUPUOLITAUDIT 17 3.4. LAPSETTOMUUS JA LAPSEN SUKUPUOLI 19 3.5. SUKUPUOLIELINTEN TRADITIONAALINEN SILPOMINEN 20 3.6. KÖYHYYDEN, TRADITIOIDEN JA OLOSUHTEIDEN MERKITYS 22 4. HAASTEET JA MAHDOLLISUUDET 23 LÄHTEET 26 QUALITY OF CARE IN REPRODUCTIVE HEALTH SERVICES AT FIVE GOVERNMENT HEALTH POSTS IN SIRAHA DISTRICT, EASTERN NEPAL ACKNOWLEDGEMENTS 1 TABLE OF CONTENTS III LIST OF TABLES VI LIST OF FIGURES VII LIST OF ABBREVATIONS AND ACRONYMS VIII GLOSSARY IX EXECUTIVE SUMMARY X CHAPTER 1. INTRODUCTION 1 1.1. THE CLIENT AND THE CONCERN 1 1.1.1. Save the Children US in Nepal 1 1.1.2. Save the Children Siraha project 1 1.1.3. Problem statement 2 1.2. THE STUDY 2 1.2.1. Study question 2 1.2.2. Aim and objectives of the study 2 1.2.1. Action plan and accomplishment of the study 3 1.3. STUDY LOCATION 4 1.3.1. Nepal 4 1.3.2. Siraha District 4 CHAPTER 2. LITERATURE REVIEW 6 2.1. GLOBAL VIEWS OF WOMEN'S HEALTH 6 2.2. PRIMARY HEALTH CARE IN NEPAL 8 2.2.1. Safe Motherhood and Family Planning 8 2.3. QUALITY IN HEALTH CARE 10 2.3.1. What is quality? 10 2.3.2. Approaches to assessment of quality in health care 10 2.4. SELECTED ISSUES IN QUALITY OF HEALTH CARE 14 2.4.1. The structure of the health care and its relevance in quality assessment 14 2.4.2. Health care providers' job motivation and its impact on quality of health care 15 2.4.3. User satisfaction 16 2.5. CONCLUSION 17 CHAPTER 3. METHODOLOGY 19 3.1. EVALUATION OF HEALTH POST FACILITIES AND SERVICE ARRANGEMENTS 20 3.1.1. Study location 20 3.1.2. Selection of health posts 20 3.1.3. Issues and variables used to explore the objective 20 3.1.4. Tools and strategies of data collection 20 3.2. EXPLORING HEALTH CARE PROVIDERS' PERCEPTIONS ABOUT THE QUALITY OF CARE 21 3.2.1. Study population 21 3.2.2. Selection of informants 21 3.2.3. Issues and variables used to explore the objective 21 3.2.4. Tools and strategies of data collection 21 3.3. DESCRIBING THE LEVEL OF USERS' SATISFACTION 22 3.3.1. Study population 22 3.3.2. Selection of informants 22 3.3.3. Issues and variables used to explore the objective 22 3.3.4. Tools and strategies of data collection 23 3.4 ADDITIONAL DATA COLLECTION METHODS 24 3.5. PRE-TESTING AND TRANSLATION 24 3.6. DATA HANDLING AND STORAGE 25 3.7. DATA ANALYSIS 25 3.8. QUALITY ASSURANCE AND ENCOUNTERED CONSTRAINTS IN DATA COLLECTION 25 CHAPTER 4. RESULTS 27 4.1. EVALUATION OF HEALTH POST FACILITIES AND SERVICE ARRANGEMENTS 27 4.1.1. Location and accessibility 27 4.1.2. Target population and service statistics 27 4.1.3. Sub-health posts, outreach clinics and staffing 28 4.2.4. Waiting facilities at health posts 28 4.1.5. Rooms for counselling and MCH and FP services 28 4.1.6. Infection prevention 29 4.1.7. Equipment and instruments for use in MCH and FP 29 4.1.8. Availability of contraceptives and essential medicines 29 4.1.9. IEC material and activities 29 4.1.10. Record keeping and reporting 30 4.1.11. Health post management and supervision 30 4.1.12. Conclusion 30 4.2. HEALTH CARE PROVIDERS' PERCEPTION ABOUT THE QUALITY OF CARE 31 4.2.1. Job satisfaction and experience as a health care provider 31 4.2.2. Health workers' perception of what is good quality in health care 32 4.2.3. Health workers' perception about users' expectations 33 4.2.4. Health workers' suggestions for improvement of health care 33 4.2.5. What are the specific reasons for low utilisation of FP and AN services 34 4.2.6. Conclusion 35 4.3. QUALITY OF CARE FROM THE USERS' POINT OF VIEW 35 4.3.1. The sample 35 4.3.2. Perceptions of the quality of care 37 4.3.3. Suggestions for improvement for the quality of care at a health post 40 4.3.4. Conclusion 40 4.4. SUMMARY OF RESULTS 41 CHAPTER 5. DISCUSSION 43 5.1. IMPACTS OF STRUCTURE OF HEALTH CARE ON QUALITY OF THE SERVICE 43 5.1.1. Accessibility 43 5.1.2. Clinical settings and procedures 44 5.1.3. Service arrangements 44 5.2. HEALTH WORKERS' ROLE 47 5.2.1. Users' expectations contradicting providers' perceptions 47 5.2.2. Implications of health workers' perceptions for improvement of quality 48 5.2.3. Job motivation 48 5.2.4. Quality assurance cycle 50 5.3. CONCLUSIONS 50 5.4. COMMENTS ON METHODS USED IN THE STUDY 51 CHAPTER 6. RECOMMENDATIONS 53 REFERENCES 54 APPENDICES APPENDIX 1 PHOTPGRAPHS: WALL PAINTINGS AND TBA TRAINING 58 APPENDIX 2 MAPS OF NEPAL AND SIRAHA DISTRICT 59 APPENDIX 3 INVENTORY FORM FOR HEALTH POST FACILITIES 60 APPENDIX 4. BACKGROUND VARIABLES 70 APPENDIX 5.A STRUCTURED QUESTIONNAIRE FOR USER EXIT INTERVIEW 71 APPENDIX 5.B MAITHALI TRANSLATION OF THE QUESTIONNAIRE 75 APPENDIX 6 EVALUATION OF HEALTH POST FACILITIES AND SERVICE ARRANGEMENTS 79 APPENDIX 7. FINDINGS FROM HEALTH PERSONNEL IN-DEPTH INTERVIEWS 84 APPENDIX 8. USERS' EXPRESSIONS OF THE QUALITY OF CARE. QUOTATIONS. 85